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BACKGROUND: Chronic kidney disease (CKD) is associated with higher incidence of major surgery. No studies have evaluated the association between preoperative kidney function and postoperative outcomes across a wide spectrum of procedures. We aimed to evaluate the association between CKD and 30-day postoperative outcomes across surgical specialties. METHODS: We selected adult patients undergoing surgery across eight specialties. The primary study endpoint was major complications, defined as death, unplanned reoperation, cardiac complication, or stroke within 30 days following surgery. Secondary outcomes included Clavien-Dindo high-grade complications, as well as cardiac, pulmonary, infectious, and thromboembolic complications. Multivariable regression was performed to evaluate the association between CKD and 30-day postoperative complications, adjusted for baseline characteristics, surgical specialty, and operative time. RESULTS: In total, 1,912,682 patients were included. The odds of major complications (adjusted odds ratio [aOR] 2.14 [95% confidence interval (CI): 2.07, 2.21]), death (aOR 3.03 [95% CI: 2.88, 3.19]), unplanned reoperation (aOR 1.57 [95% CI: 1.51, 1.64]), cardiac complication (aOR 3.51 [95% CI: 3.25, 3.80]), and stroke (aOR 1.89 [95% CI: 1.64, 2.17]) were greater for patients with CKD stage 5 vs. stage 1. A similar pattern was observed for the secondary endpoints. CONCLUSION: This population-based study demonstrates the negative impact of CKD on operative outcomes across a diverse range of procedures and patients.

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Importance: Gender inequities and limited representation are an obstacle to surgical workforce diversification. There has been limited examination of gender-based disparities in billing practices among surgeons. Objective: To evaluate variations in practice metrics and billing practices among female and male surgeons and identify factors associated with gender disparities in Medicare reimbursements. Design, Setting, and Participants: This retrospective cross-sectional study used publicly available Medicare Fee-for-Service Provider Utilization and Payment data from January to December 31, 2021, to identify demographics, annual services provided, and financial payments and charges for general surgeons, surgical oncologists, and colorectal surgeons. Data were analyzed from November 2023 to February 2024. Exposure: The primary exposure of interest was surgeon gender (ie, female or male). Main Outcomes and Measures: The annual total submitted charges and payments submitted in 2021 by female and male surgeons were assessed. Additionally, the total number and types of services provided each year and the number of beneficiaries treated were examined. Multivariable linear regression models were used to evaluate the association of surgeon gender with payments, number of services, and beneficiaries. Results: A total of 20 549 general surgeons (5036 [24.5%] female; 15 513 [75.5%] male), 1065 surgical oncologists (450 [42.3%] female; 615 [57.7%] male), and 1601 colorectal surgeons (432 [27.0%] female; 1169 [73.0%] male) were included. Across all surgical subspecialties, female surgeons billed fewer mean (SE) Medicare charges (general surgeons: 30.1% difference; $224 934.80 [$3846.97] vs $321 868.50 [$3933.57]; surgical oncologists: 27.5% difference; $277 901.70 [$22 857.37] vs $382 882.90 [$19 566.06]; colorectal surgeons: 21.7% difference; $274 091.70 [$10 468.48] vs $350 146.10 [$8741.66]; all P < .001) and received significantly lower mean (SE) reimbursements (general surgeons: 29.0% difference; $51 787.61 [$917.91] vs $72 903.12 [$890.35]; surgical oncologists: 23.6% difference; $57 945.18 [$3853.28] vs $75 778.22 [$2622.75]; colorectal surgeons: 24.5% difference; $63 117.01 [$2248.10] vs $83 598.53 [$1934.77]; all P < .001). On multivariable analysis, a reimbursement gap remained across all 3 surgical subspecialties (general surgeons: -$14 963.46 [95% CI, -$18 822.27 to -$11 104.64] [P < .001]; surgical oncologists: -$8354.69 [95% CI, -$15 018.12 to -$1691.25] [P = .01]; colorectal surgeons: -$4346.73 [95% CI, -$7660.15 to -$1033.32] [P = .01]). Conclusions and Relevance: In this cross-sectional study, there was considerable gender-based variation in practice patterns and reimbursement among different surgical subspecialties serving the Medicare population. Differences in mean payment per service were associated with variations in billing and coding strategies among female and male surgeons.

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BACKGROUND: COVID-19 had a tremendous impact on surgical residency education and training. With little experience or training in using online learning in pedagogically informed ways, some surgical educators and learners experienced the disadvantages of online learning which may have contributed to a greater sense of burnout in the pandemic. The purpose of this study is to survey the level of burnout in surgical educators and assess educators' perspectives on factors that increased or decreased burnout in synchronous online teaching during the pandemic. METHODS: A cross-sectional study consisting of 4 sections was sent to surgical educators at the University of Toronto. Demographic data, validated surveys on burnout and videoconferencing fatigue (the Maslach Burnout Inventory-Educators Survey (MBI-ES) and the Zoom Exhaustion and Fatigue (ZEF) scale respectively), and quantitative questions about teaching factors in synchronous online environments were collected and analyzed. RESULTS: The MBI-ES demonstrated a high degree of emotional exhaustion, and depersonalization and a moderate degree of personal accomplishment in surgeon educators. The ZEF scale noted moderate fatigue across all domains. Although educators noted online learning to be a moderate factor contributing to burnout during the pandemic, there was no correlation between the number of hours or percentage of time teaching online to burnout or zoom fatigue scores. The largest reported contributing factor to online learning leading to burnout was lack of connection to learners, whereas the largest mitigating factor was decreased travel time. INTERPRETATIONS: The study found a moderate degree of exhaustion and burnout among surgical educators in Canada during COVID-19 and examined how aspects of online synchronous learning may have contributed to or helped mitigate these experiences. Based on this, we present approaches and educational theories to improve the online learning experience for surgical educators going forward.

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INTRODUCTION: Transitioning patients from their paediatric centres to adulthood is an important subject for many of these patients living with different chronic pathologies. There are few studies that assess its effectiveness in paediatric surgical pathologies. The overall objective of this scoping review is to assess the extent of the literature describing transitional programmes dedicated to young patients living with surgical conditions. The primary question will look to assess what transitional programmes are available for young patients living with surgical conditions either operated or not. METHODS AND ANALYSIS: The proposed scoping review will follow guidelines described by the Joanna Briggs Institute manual described by Peters et al in 2020. This protocol will employ the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols checklist. The concept that will be included in this review is the exposure of these patients to a transition of care pathway or care programmes. Patients between the ages of 16 and 30 with a surgical condition will be included. There will be no comparator. No specific outcomes will be assessed, however, the outcomes that will be found from the transition programmes will be reviewed. A knowledge synthesis librarian will search MEDLINE All (Ovid), Embase (Ovid), Web of Science Core Collection (Clarivate) and CINAHL Complete (EBSCOhost). The literature search will be limited to 2000 onwards publications. No language or age group limitation will be applied. The reference list of all included sources of evidence will be screened for additional studies. Screening of search results and data extraction from included studies will be completed in Covidence by two independent reviewers. We will also use the PAGER (Patterns, Advances, Gaps, Evidence for practice and Research recommendations) framework to report and summarise the results. ETHICS AND DISSEMINATION: This review does not require ethics approval. Our dissemination strategy includes peer review publication, conference presentation, co-constructed guidelines with stakeholders and policymakers. TRIAL REGISTRATION: This review is registered on OSF.

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Background: Equatorial Guinea (EG) is located on the African west coast, with only 0.4 trained physicians per 1,000 resident population. The country has one medical school and there is no specialist training program. From 2000 to 2022, 524 doctors have received their medical degree. However, the number of national surgical specialists in the entire country is currently 42. Objective: Formación Especializada Sanitaria en Guinea Ecuatorial (FES Guinea) is a program specifically aimed at designing and implementing a long-term national surgical specialist training program. Methods: Más Que Salud (+QS), which means "More than Health" in Spanish, is a nonprofit organization leading the FES Guinea program. We used the theory of change (ToC) framework to evaluate the work accomplished and implement subsequent phases. The initial phase (A) included a needs assessment and mapping of available resources. An intermediate phase (B) started with a memorandum of understanding to implement a Train the Trainer program. The consolidation phase (C) consists of educational interventions and future advanced training projects. Findings: The ToC model allowed us an analyses of initial and intermediate phases. The needs assessments and resources mapping were executed while several scientific meetings and workshops were given. Scholarships to support specialist training abroad benefited six physicians in a diverse set of surgical disciplines. A regulatory commission to implement the FES Guinea program and the National Medical Council of EG were created. Working directly with the EG Ministry of Health, +QS codesigned a National Health Development Plan that began implementation in 2021 to continue until 2025. Conclusions: The ToC model allowed us to predict the current and future potential effects of FES Guinea on surgical workforce development in EG. This is a unique surgical training program, which combined effective initiatives spearheaded initially by an NGO that successfully incorporated both local health and academic authorities, ensuring sustainability.

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BACKGROUND: Emergency presentations make up a large proportion of a general surgeon's workload. Patients who have emergency surgery carry a higher rate of mortality and complications. We aim to review the impact of surgical subspecialization on patients following upper gastrointestinal (UGI) emergency surgery. METHODS: A systematic search of Ovid Embase, Ovid MEDLINE, and Cochrane databases using a predefined search strategy was completed reviewing studies published from 1st of January 1990 to August 27, 2023. The study was prospectively registered with PROSPERO (CRD42022359326). Studies were reviewed for the following outcomes: 30-day mortality, in-hospital mortality, conversion to open, length of stay, return to theater, and readmission. RESULTS: Of 5181 studies, 24 articles were selected for full text review. Of these, seven were eligible and included in this study. There was a statistically significant improvement in 30-day mortality favoring UGI specialists (OR 0.71 [95% CI 0.55-0.92 and p = 0.009]) and in-hospital mortality (OR 0.29 [95% CI 0.14-0.60 and p = 0009]). There was a high degree of study heterogeneity in 30-day mortality; however, a low degree of heterogeneity within in-hospital mortality. There was no statistical significance when considering conversion to open and insufficient data to allow meta-analysis for return to theater or readmission rates. CONCLUSION: In emergency UGI surgery, there was improved 30-day and in-hospital mortality for UGI specialists. Therefore, surgeons should consider early involvement of a subspecialist team to improve patient outcomes.

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AIM: To evaluate effect of surgeon's seniority (trainee surgeon vs. consultant surgeon) and surgeon's subspeciality interest on postoperative mortality in patients undergoing emergency laparotomy (EL). METHOD: A systematic review was conducted and reported according to the Cochrane Handbook for Systematic Reviews and the PRISMA statement standards, respectively. We evaluated all studies comparing the risk of postoperative mortality in patients undergoing EL between (a) trainee surgeon and consultant surgeon, and (b) surgeon without and with subspeciality interest related to pathology. Random effects modelling was applied for the analyses. The certainty of evidence was assessed using the GRADE system. RESULTS: Analysis of 256 844 patients from 13 studies showed no difference in the risk of postoperative mortality between trainee-led and consultant-led EL (OR: 0.76, p = 0.12). However, EL performed by a surgeon without subspeciality interest related to the pathology was associated with a higher risk of postoperative mortality compared with a surgeon with subspeciality interest (OR: 1.38, p < 0.00001). In lower gastrointestinal (GI) pathologies, EL done by upper GI surgeons resulted in higher risk of mortality compared with lower GI surgeons (OR: 1.43, p < 0.00001). In upper GI pathologies, EL done by lower GI surgeons resulted in higher risk of mortality compared with upper GI surgeons (OR: 1.29, p = 0.05). CONCLUSION: While confounding by indication cannot be excluded, level 2 evidence with moderate certainty suggests that trainee-led EL may not increase the risk of postoperative mortality but EL by a surgeon with subspeciality interest related to the pathology may reduce the risk of mortality.

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OBJECTIVES: Previous literature has consistently documented harassment and discrimination in surgery. These experiences may contribute to the continuing gender inequity in surgical fields. The objective of our study was to survey Canadian surgeons and surgical trainees to gain a greater understanding of the experience of harassment across genders, career stage, and specialty. METHODS: A cross-sectional, online survey was distributed to Canadian residents, fellows, and practicing surgeons in general surgery, plastic surgery, and neurosurgery through their national society email lists and via social media posts. RESULTS: There were 194 included survey respondents (60 residents, 11 fellows, and 123 staff) from general surgery (44.8%), plastic surgery (42.7%), and neurosurgery (12.5%). 59.8% of women reported having experienced harassment compared to only 26.0% of men. Women were significantly more likely to be harassed by colleagues and patients/families compared to men. Residents (62.5%) were two times more likely to report being harassed compared to fellows/staff (38.3%). Residents were significantly more likely to be harassed by patients/families while fellows/staff were more likely to be harassed by colleagues. There were no significant differences in self-reported harassment across the three surgical specialties. There was no significant difference in rates of reported harassment between current residents (62.5%), and fellow/staff recollections of their experiences of harassment during residency (59.2%). CONCLUSIONS: The prevalence of gender-based discrimination remains high and harassment prevalence remains largely unchanged from when current staff were in residency. Our findings highlight a need to implement systemic changes to support the increasing number of women entering surgery, and to improve surgical culture to continue to attract the best and brightest to the field.

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PURPOSE: Pediatric surgical care in low- and middle-income countries is often hindered by systemic gaps in healthcare resources, infrastructure, training, and organization. This study aims to develop and validate the Global Assessment of Pediatric Surgery (GAPS) to appraise pediatric surgical capacity and discriminate between levels of care across diverse healthcare settings. METHODS: The GAPS Version 1 was constructed through a synthesis of existing assessment tools and expert panel consultation. The resultant GAPS Version 2 underwent international pilot testing. Construct validation categorized institutions into providing basic or advanced surgical care. GAPS was further refined to Version 3 to include only questions with a > 75% response rate and those that significantly discriminated between basic or advanced surgical settings. RESULTS: GAPS Version 1 included 139 items, which, after expert panel feedback, was expanded to 168 items in Version 2. Pilot testing, in 65 institutions, yielded a high response rate. Of the 168 questions in GAPS Version 2, 64 significantly discriminated between basic and advanced surgical care. The refined GAPS Version 3 tool comprises 64 questions on: human resources (9), material resources (39), outcomes (3), accessibility (3), and education (10). CONCLUSION: The GAPS Version 3 tool presents a validated instrument for evaluating pediatric surgical capabilities in low-resource settings.

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INTRODUCTION: This academic article discusses the historical underrepresentation of female in science, with a focus on Latin America. It highlights the importance of both technical and non-technical skills in the medical-surgical field, particularly the role of research skills. The study aims to quantify and characterize the scientific output of Latin American female researchers over the past decade, providing insights into the challenges and opportunities in low and middle-income countries. MATERIAL AND METHODS: A retrospective cross-sectional bibliometric study was conducted in 2023, focusing on pediatric surgical science journals in Scopus and PubMed. It assessed Latin American female participation, journal details, and interaction networks, using SPSS and Gephi software. The period analyzed was from January 2012 to December 2022. RESULTS: Between 2012 and 2022, 727 articles with Latin authorship in pediatric surgery were analyzed across 304 journals. Of these, 63.69% had female co-authors. The majority were original articles (53.13%), with contributions from Brazil, Mexico, and Chile. Notable journals included the Journal of Pediatric Surgery and Child's Nervous System. Keywords like Laparoscopy and Cardiac surgery were common. A growth trend in female Latin American publications was observed, despite temporary declines. CONCLUSIONS: This study highlights a growing trend in Latin American females' scientific contributions to pediatric surgery from 2012 to 2022, although a gender gap persists. The research mainly consists of primary data studies, with a focus on Brazil and Mexico from public institutions. The Journal of Pediatric Surgery featured prominently, and common topics included Laparoscopy, Cardiac surgery, Liver transplant, Congenital heart defects, and COVID-19. LEVEL OF EVIDENCE: IV.

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The American Pediatric Surgical Association (APSA) Practice Committee endorsed by the Board of Governors presents a Position Statement on the role of locum tenens in the practice of pediatric surgery. The Practice Committee also presents a set of guidelines for locum tenens practice. These recommendations highlight safe practice and quality care that protects the patient as well as the pediatric surgeon by offering best practice standards, defining optimal resources and establishing parameters by which hospitals and locum tenens agencies should abide. These guidelines are intended to foster discussion and contract negotiation as well as inform decision making for a) pediatric surgeons considering locum tenens opportunities, b) host organizations (hospitals and practices) seeking the coverage of a pediatric surgeon, and c) locum tenens companies vetting both surgeons and hospitals for appropriateness of such coverage. This Position Statement and foundational set of guidelines align with APSA's Vision (all children receive the highest quality surgical care) and Mission (to provide the best surgical care to our patients and families by supporting an inclusive community through education, discovery and advocacy).

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INTRODUCTION: National Institute of Health (NIH) funding is a "gold-standard" of achievement; we examined trends in NIH-funded pediatric surgeons. METHODS: NIH Research Portfolio Online Reporting Tools (RePORT) was queried for American Pediatric Surgical Association (APSA) members (2012 vs 2022). Demographics and time-to-award (TTA) from fellowship were compared. Number of grants, funding allotment, award classification, administering institutes/centers, research type were studied. RESULTS: Thirty-eight (4.6%) APSA members were NIH-funded in 2012 compared to 37 (2.9%) in 2022. Of funded surgeons in 2022, 27% were repeat awardees from 2012. TTA was similar (12 vs 14years, p=0.109). At each point, awards were commonly R01 grants (40 vs 52%, p â€‹= â€‹0.087) and basic science-related (76 vs 63%, p = â€‹0.179). Awardees were predominantly men (82% in 2012 vs 78% in 2022, p=0.779) and White (82% in 2012 vs 76% in 2022, p=0.586). Median amount per grant increased: $254,980 (2012) to $364,025 (2022); by $96,711 for men and $390,911 for women. Median awards for White surgeons increased by $215,699 (p=0.035), and decreased by $30,074 for non-White surgeons, though not significantly (p=0.368). CONCLUSION: The landscape of NIH-funded pediatric surgeons has remained unchanged between time points. With a substantial number of repeat awardees, predominance of R01 grants, and a median TTA over a decade after fellowship graduation, the phenotypes of early career pediatric surgeon-scientists are facing academic endangerment.

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OBJECTIVE: This study aimed to analyze the trends of Medicare physician reimbursement from 2011 to 2021 and compare the rates across different surgical specialties. BACKGROUND: Knowledge of Medicare is essential because of its significant contribution in physician reimbursements. Previous studies across surgical specialties have demonstrated that Medicare, despite keeping up with inflation in some areas, has remained flat when accounting for physician reimbursement. STUDY DESIGN: The Physician/Supplier Procedure Summary data for the calendar year 2021 were queried to extract the top 50% of Current Procedural Terminology codes based on case volume. The Physician Fee Schedule look-up tool was accessed, and the physician reimbursement fee was abstracted. Weighted mean reimbursement was adjusted for inflation. Growth rate and compound annual growth rate were calculated. Projection of future inflation and reimbursement rates were also calculated using the US Bureau of Labor Statistics. RESULTS: After adjusting for inflation, the weighted mean reimbursement across surgical specialties decreased by -22.5%. The largest reimbursement decrease was within the field of general surgery (-33.3%), followed by otolaryngology (-31.5%), vascular surgery (-23.3%), and plastic surgery (-22.8%). There was a significant decrease in median case volume across all specialties between 2011 and 2021 (P < 0.001). CONCLUSIONS: This study demonstrated that, when adjusted for inflation, over the study period, there has been a consistent decrease in reimbursement for all specialties analyzed. Awareness of the current downward trends in Medicare physician reimbursement should be a priority for all surgeons, as means of advocating for compensation and to maintain surgical care feasible and accessible to all patients.

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Congenital heart disease (CHD) affects eight to ten out of every 1,000 births, resulting in approximately 23,057 new cases in Brazil in 2022. About one in four children with CHD requires surgery or other procedures in the first year of life, and it is expected that approximately 81% of these children with CHD will survive until at least 35 years of age. Professionals choosing to specialize in CHD surgery face numerous challenges, not only related to mastering surgical techniques and the complexity of the diseases but also to the lack of recognition by medical societies as a separate subspecialty. Furthermore, families face difficulties when access to services capable of providing treatment for these children. To address these challenges, it is essential to have specialized hospitals, qualified professionals, updated technologies, sustainable industry, appropriate financing, quality assessment systems, and knowledge generation. The path to excellence involves specialization across all involved parties. As we reflect on the importance of Pediatric Cardiovascular Surgery and Congenital Heart Diseases establishing themselves as a subspecialty of Cardiovascular Surgery, it is essential to look beyond our borders to countries like the United States of America and United Kingdom, where this evolution is already a reality. This autonomy has led to significant advancements in research, education, and patient care outcomes, establishing a care model. By following this path in Brazil, we not only align our practice with the highest international standards but also demonstrate our maturity and the ability to meet the specific needs of patients with CHD and those with acquired childhood heart disease.

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BACKGROUND: The Global Initiative for Children's Surgery group published the Optimal Resources for Children's Surgery (OReCS) document outlining the essential criteria and strategies for children's surgical care in low-resource settings. Limited data exist on subspecialties in pediatric surgery and their contribution to global surgery efforts. The study aimed to evaluate the development of subspecialty units within Chris Hani Baragwanath Academic Hospital (CHBAH) Department of Pediatric Surgery (DPS) from January 1, 2018 to December 31, 2021 using selected OReCS strategies for the improvement of pediatric surgery. METHODS: A retrospective descriptive research design was followed. The study population consisted of CHBAH PSD records. The following data were collected: number of patients managed in PSD subspecialty unit (the units) clinics and surgeries performed, number of trainees, available structures, processes and outcome data, and research output. RESULTS: Of the 17,249 patients seen in the units' outpatient clinics, 8275 (47.9%) burns, 6443 (37.3%) colorectal, and 2531 (14.6%) urology. The number of surgeries performed were 3205, of which 1306 (40.7%) were burns, 644 (20.1%) colorectal, 483 (15.1%) urology, 341 (10.6%) hepatobiliary, and 431 (12.8%) oncology. Of the 16 selected strategies evaluated across the 5 units, 94% were available, of which 16.4% was partly provided by Surgeons for Little Lives. Outcome data in the form of morbidity and mortality reviews for all the units is available, but there is no data for timeliness of care with waiting lists. There were 77 publications and 41 congress presentations. CONCLUSION: The subspecialty units respond to the global surgical need by meeting most selected OReCS resources in the clinical service provided.

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The article discusses the evolution of the Brazilian College of Surgeons (CBC) specialist title exam, highlighting the importance of evaluating not only theoretical knowledge, but also the practical skills and ethical behavior of candidates. The test was instituted in 1971, initially with only the written phase, and later included the oral practical test, starting with the 13th edition in 1988. In 2022, the assessment process was improved by including the use of simulated stations in the practical test, with the aim of assessing practical and communication skills, as well as clinical reasoning, in order to guarantee excellence in the assessment of surgeons training. The aim of this study is to demonstrate the performance of candidates in the last five years of the Specialist Title Test and to compare the performance results between the different surgical training groups of the candidates. The results obtained by candidates from the various categories enrolled in the test in the 2018 to 2022 editions were analyzed. There was a clear and statistically significant difference between doctors who had completed three years of residency recognized by the Ministry of Education in relation to the other categories of candidates for the Specialist Title..

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OBJECTIVE: Attrition rates among general surgery residents are notoriously high relative to other specialties. The aim of this study was to compare annual resident attrition rates between general surgery and other surgical subspecialties and to examine these trends in recent years. DESIGN: This was a retrospective study performed using Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books from 2012-2022. Annual attrition rate and average ten-year attrition rate were calculated for general surgery and surgical specialties. Differences were assessed by Pearson chi-square test. SETTING: All ACGME accredited residency programs in the United States were included. RESULTS: General surgery residencies had a significantly higher average annual attrition rate (3.3%) than all other surgical specialties studied except thoracic surgery. Most attrition among general surgery residents was voluntary and these rates did not appear to be affected by the COVID-19 pandemic. CONCLUSIONS: Attrition among general surgery residents is higher than in other surgical specialties, suggesting that early specialization may be protective against resident attrition.

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