1- and 2-year outcomes and predictors of weight loss after gastric sleeve to Roux-en-Y gastric bypass conversion: a retrospective cohort study.

BACKGROUND: Sleeve gastrectomy to Roux-en-Y bypass conversion is a commonly performed procedure, yet data are limited on outcomes and their predictors. The purpose of this study is to characterize the long-term outcomes of patients after sleeve-to-bypass conversion and identify predictors of post-conversion outcomes. METHODS: We performed a retrospective cohort study of patients who underwent sleeve-to-bypass conversion for obesity across four hospitals from 06/2017 to 04/2023. Predictors of the below-average percent excess weight loss (%EWL; relative to pre-conversion weight) at 1 and 2 years following conversion were identified using multivariate logistic regression models adjusting for comorbidities, demographics, and neighborhood socioeconomic status. RESULTS: 150 Patients undergoing sleeve-to-bypass conversion were identified. 99 had 1-year data and 63 had 2-year data. Mean %EWL at 1- and 2-years following conversion were 40.2% and 37.4%, respectively. EWL > 40% after sleeve gastrectomy was an independent predictor of the below-average %EWL 1-year post-conversion (OR 10.0, 95% CI 2.2-63.0, p < 0.01), and BMI > 40 kg/m2 at the time of conversion was an independent predictor of both 1- and 2-year below-average %EWL post-conversion (p = 0.01 and 0.05, respectively). Insignificant predictors of the below-average %EWL after conversion included: weight regain after sleeve, time between sleeve and conversion, alimentary limb length, and any bariatric surgery prior to sleeve gastrectomy. CONCLUSION: Patients should be counseled that the typical expected %EWL for sleeve-to-bypass conversion is less than the 50% EWL benchmark of success for index bariatric operations. The main predictors of a suboptimal conversion outcome are > 40% EWL after sleeve or > 40 BMI kg/m2 at the time of conversion. Most variables in our analysis were not predictors of post-conversion %EWL, including weight regain between sleeve and conversion, alimentary limb length, and time interval between procedures, which suggests that these factors should not play a large role when considering sleeve-to-bypass conversion.

Advancing global antibiotic research, development and access.

The pipeline of new antibiotics is insufficient to keep pace with the growing global burden of drug-resistant infections. Substantial economic challenges discourage private investment in antibiotic research and development (R&D), with a decline in the number of companies and researchers working in the field. Compounding these issues, many countries (from low income to high income) face a growing crisis of antibiotic shortages and inequitable access to existing and emerging treatments. This has led to an increasing role for public and philanthropic funding in supporting antibiotic R&D via the creation of nonprofit public-private partnerships, including Combating Antibiotic-Resistant Bacteria Biopharmaceutical Accelerator (CARB-X) and the Global Antibiotic Research and Development Partnership (GARDP), industry support for the AMR Action Fund, and pilot schemes to evaluate and reimburse antibiotics in innovative ways. Now is the time to raise the urgency, ambition and commitments of the world's leaders to fully support the antibiotic R&D ecosystem, incentivizing all sectors to conduct public health-driven antibiotic R&D and make effective antibiotics accessible to all who need them.

Current status of resident simulation training curricula: pearls and pitfalls.

BACKGROUND: Residency programs are required to incorporate simulation into their training program. Ideally, simulation provides a safe environment for a trainee to be exposed to both common and challenging clinical scenarios. The purpose of this review is to detail the current state of the most commonly used laparoscopic, endoscopic, and robotic surgery simulation programs in general surgery residency education, including resources required for successful implementation and benchmarks for evaluation. MATERIALS AND METHODS: Members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Resident and Fellow Task Force (RAFT) Committee performed a literature review using PubMed and training websites. Information regarding the components of the most commonly used laparoscopic, endoscopic, and/or robotic simulation curriculum, including both formal and informal benchmarks for evaluating training competence, were collected. RESULTS: Laparoscopic simulation revolves around the Fundamentals of Laparoscopic Surgery (FLS). Proficiency-based as well as virtual simulation have been utilized for FLS training curricula. Challenges include less direct translation to the technical complexities that can arise in laparoscopic surgery. Endoscopic simulation focuses on the Fundamentals of Endoscopic Surgery. There are virtual reality simulation platforms that can be used for skills assessment and training. Challenges include simulator types and access, as well as structured mentoring and feedback. Robotic simulation training curricula have not been standardized. Simulation includes one primary technology, which can be prohibitive based on cost and requirements for onboarding. CONCLUSIONS: While surgical simulation seems to be a fundamental and integrated part of surgical training, it requires a significant number of resources, which can be daunting for residency training programs. Regardless of the barriers outlined, the need for surgical simulation in laparoscopy, endoscopy, and robotics at surgical education training programs is clear.

Perspectives on sustainability among surgeons: findings from the SAGES-EAES sustainability in surgical practice task force survey.

BACKGROUND: Surgical care significantly contributes to healthcare-associated greenhouse gas emissions (GHG). Surgeon attitudes about mitigation of the impact of surgical practice on environmental sustainability remains poorly understood. To better understand surgeon perspectives globally, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association for Endoscopic Surgery established a joint Sustainability in Surgical Practice (SSP) Task Force and distributed a survey on sustainability. METHODS: Our survey asked about (1) surgeon attitudes toward sustainability, (2) ability to estimate the carbon footprint of surgical procedures and supplies, (3) concerns about the negative impacts of sustainable interventions, (4) willingness to change specific practices, and (5) preferred educational topics and modalities. Questions were primarily written in Likert-scale format. A clustering analysis was performed to determine whether survey respondents could be grouped into distinct subsets to inform future outreach and education efforts. RESULTS: We received 1024 responses, predominantly from North America and Europe. The study revealed that while 63% of respondents were motivated to enhance the sustainability of their practice, less than 10% could accurately estimate the carbon footprint of surgical activities. Most were not concerned that sustainability efforts would negatively impact their practice and showed readiness to adopt proposed sustainable practices. Online webinars and modules were the preferred educational methods. A clustering analysis identified a group particularly concerned yet willing to adopt sustainable changes. CONCLUSION: Surgeons believe that operating room waste is a critical issue and are willing to change practice to improve it. However, there exists a gap in understanding the environmental impact of surgical procedures and supplies, and a sizable minority have some degree of concern about potential adverse consequences of implementing sustainable policies. This study uniquely provides an international, multidisciplinary snapshot of surgeons' attitudes, knowledge, concerns, willingness, and preferred educational modalities related to mitigating the environmental impact of surgical practice.

Scoping review for the SAGES EAES joint collaborative on sustainability in surgical practice.

BACKGROUND: Surgical care in the operating room (OR) contributes one-third of the greenhouse gas (GHG) emissions in healthcare. The European Association of Endoscopic Surgery (EAES) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) initiated a joint Task Force to promote sustainability within minimally invasive gastrointestinal surgery. METHODS: A scoping review was conducted by searching MEDLINE via Ovid, Embase via Elsevier, Cochrane Central Register of Controlled Trials, and Scopus on August 25th, 2023 to identify articles reporting on the impact of gastrointestinal surgical care on the environment. The objectives were to establish the terminology, outcome measures, and scope associated with sustainable surgical practice. Quantitative data were summarized using descriptive statistics. RESULTS: We screened 22,439 articles to identify 85 articles relevant to anesthesia, general surgical practice, and gastrointestinal surgery. There were 58/85 (68.2%) cohort studies and 12/85 (14.1%) Life Cycle Assessment (LCA) studies. The most commonly measured outcomes were kilograms of carbon dioxide equivalents (kg CO2eq), cost of resource consumption in US dollars or euros, surgical waste in kg, water consumption in liters, and energy consumption in kilowatt-hours. Surgical waste production and the use of anesthetic gases were among the largest contributors to the climate impact of surgical practice. Educational initiatives to educate surgical staff on the climate impact of surgery, recycling programs, and strategies to restrict the use of noxious anesthetic gases had the highest impact in reducing the carbon footprint of surgical care. Establishing green teams with multidisciplinary champions is an effective strategy to initiate a sustainability program in gastrointestinal surgery. CONCLUSION: This review establishes standard terminology and outcome measures used to define the environmental footprint of surgical practices. Impactful initiatives to achieve sustainability in surgical practice will require education and multidisciplinary collaborations among key stakeholders including surgeons, researchers, operating room staff, hospital managers, industry partners, and policymakers.

Falling short in bariatric surgery: An exploration of key barriers and motivators of attrition.

BACKGROUND: In the United States, obesity-related diseases pose significant healthcare challenges, with bariatric surgery offering a potential solution. However, bariatric surgery completion rates, particularly among Black and Hispanic populations, remain low. OBJECTIVE: This study applied the Theoretical Domains Framework (TDF) to explore behavioral factors influencing bariatric surgery program attrition among a majority Black participant population to inform interventions for improving attrition. METHODS: We conducted semi-structured interviews with 40 surgical and non-surgical participants and conducted deductive content analysis informed by six TDF constructs to explore factors influencing bariatric surgery program attrition. RESULTS: Participants' decision-making regarding bariatric surgery is influenced by behavioral factors, including knowledge, skills, social roles, beliefs about capabilities, optimism, and beliefs about consequences. CONCLUSION: Understanding multifaceted factors influencing bariatric surgery attrition will inform the development of tailored interventions that address knowledge gaps, enhance skills, and consider social role conflicts to improve patient engagement and decision-making in managing obesity, especially for Black populations.

Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

Improving equitable access for effective antibacterial: an ecosystem approach.

BACKGROUND: Antibiotics are indispensable to modern healthcare, yet their equitable access remains a pressing global challenge. Factors contributing to inequities include insufficient evidence for optimal clinical use, limited registration, pricing for Reserve antibiotics, and supply chain challenges. These issues disproportionately affect low- and middle-income countries, exacerbating antimicrobial resistance burdens. OBJECTIVES: This paper explores the multifaceted dimensions of inequitable antibiotic access and proposes a comprehensive framework to address the crisis. SOURCES: Published articles, grey literature analysis, and the authors' own expertise contributed to this article. CONTENT: While much attention has been paid to push-and-pull incentives for antibiotic development, these interventions are inadequate to reach sustainable and equitable access to antibiotics. Improving equitable antibiotic access requires an ecosystem approach, involving multiple stakeholders and including public-private partnerships. The paper advocates for initiatives spanning research and development, regulatory pathways, procurement strategies, and financing mechanisms and suggests concrete interventions in each of these areas. The specific interventions and mix of public and private actors may vary according to antibiotic, market, and health system context, but must be designed to meet public health needs while also supporting a market that will sustain quality-assured production and delivery of antibiotics. IMPLICATIONS: Addressing the challenge of equitable antibiotic access requires coordinated efforts across sectors and regions. By embracing an ecosystem approach centred on public health priorities, stakeholders can pave the way for a sustainable supply of antibiotics, and equitable access, safeguarding the future of global healthcare amidst the growing threat of antimicrobial resistance.

Ensuring progress on sustainable access to effective antibiotics at the 2024 UN General Assembly: a target-based approach.

Rising antimicrobial resistance (AMR) is a global health crisis for countries of all economic levels, alongside the broader challenge of access to antibiotics. As a result, development goals for child survival, healthy ageing, poverty reduction, and food security are at risk. Preserving antimicrobial effectiveness, a global public good, requires political will, targets, accountability frameworks, and funding. The upcoming second high-level meeting on AMR at the UN General Assembly (UNGA) in September, 2024, is evidence of political interest in addressing the problem of AMR, but action on targets, accountability, and funding, absent from the 2016 UNGA resolution, is needed. We propose ambitious yet achievable global targets for 2030 (relative to a prepandemic 2019 baseline): a 10% reduction in mortality from AMR; a 20% reduction in inappropriate human antibiotic use; and a 30% reduction in inappropriate animal antibiotic use. Given national variation in current levels of antibiotic use, these goals (termed the 10-20-30 by 2030) should be met within a framework of universal access to effective antibiotics. The WHO Access, Watch, Reserve (AWARE) system can be used to define, monitor, and evaluate appropriate levels of antibiotic use and access. Some countries should increase access to narrow-spectrum, safe, and affordable (Access) antibiotics, whereas others should discourage the inappropriate use of broader-spectrum (Watch) and last-resort (Reserve) antibiotics; AWARE targets should use a risk-based, burden-adjusted approach. Improved infection prevention and control, access to clean water and sanitation, and vaccination coverage can offset the selection effects of increased antibiotic use in low-income settings. To ensure accountability and global scientific guidance and consensus, we call for the establishment of the Independent Panel on Antimicrobial Access and Resistance and the support of leaders from low-income and middle-income countries.

SAGES White Paper on the importance of diversity in surgical leadership: creating the fundamentals of leadership development (FLD) curriculum.

BACKGROUND: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has long recognized and championed increasing diversity within the surgical workplace. SAGES initiated the Fundamentals of Leadership Development (FLD) Curriculum to address these needs and to provide surgeon leaders with the necessary tools and skills to promote diversity, equity, and inclusion (DEI) in surgical practice. In 2019, the American College of Surgeons issued a request for anti-racism initiatives which lead to the partnering of the two societies. The primary goal of FLD was to create the first surgeon-focused leadership curriculum dedicated to DEI. The rationale/development of this curriculum and its evaluation/feedback methods are detailed in this White Paper. METHODS: The FLD curriculum was developed by a multidisciplinary task force that included surgeons, education experts, and diversity consultants. The curriculum development followed the Analysis, Design, Development, Implementation and Evaluation (ADDIE) instructional design model and utilized a problem-based learning approach. Competencies were identified, and specific learning objectives and assessments were developed. The implementation of the curriculum was designed to be completed in short intervals (virtual and in-person). Post-course surveys used the Kirkpatrick's model to evaluate the curriculum and provide valuable feedback. RESULTS: The curriculum consisted of interactive online modules, an online discussion forum, and small group interactive sessions focused in three key areas: (1) increasing pipeline of underrepresented individuals in surgical leadership, (2) healthcare equity, and (3) conflict negotiation. By focusing on positive action items and utilizing a problem-solving approach, the curriculum aimed to provide a framework for surgical leaders to make meaningful changes in their institutions and organizations. CONCLUSION: The FLD curriculum is a novel leadership curriculum that provided surgeon leaders with the knowledge and tools to improve diversity in three areas: pipeline improvement, healthcare equity, and conflict negotiation. Future directions include using pilot course feedback to enhance curricular effectiveness and delivery.

Age is just a number: The role of advanced age in predicting complications following ventral hernia repair with component separation.

BACKGROUND: While advanced age is often considered a risk factor for complications following abdominal surgery, its impact on outcomes after complex open ventral hernia repair (VHR) with component separation technique (CST) remains unclear. METHODS: A single-center retrospective review of patients who VHR with CST from November 2008 to January 2022 was performed and cohorts were stratified by presence of advanced age (≥60 years). RESULTS: Of 219 patients who underwent VHR with CST, 114 patients (52.1 â€‹%) were aged ≥60 years. Multivariate analysis demonstrated BMI to be an independent predictor for any complication (OR 1.1, p â€‹= â€‹0.002) and COPD was positively associated with seroma development (OR 20.1, p â€‹= â€‹0.012). Advanced age did not independently predict postoperative outcomes, including hernia recurrence (OR 0.8, p â€‹= â€‹0.766). CONCLUSIONS: VHR with CST is generally safe to perform in patients of advanced age. Every patient's comorbidity profile should be thoroughly assessed preoperatively for risk stratification regardless of age.

Prospects for dog rabies elimination in Nigeria by 2030.

The attainment of the global target of zero dog-mediated human rabies by 2030 depends on functional rabies programmes. Nigeria, a rabies-endemic country, and the most populous country in Africa has a very poor rabies control strategy with a score of 1.5 out of 5 based on the Stepwise Approach towards Rabies Elimination (SARE). In this article, we report a scoping review that we conducted to highlight the strengths, weaknesses, opportunities and threats as well as situational analysis of rabies control in Nigeria and suggest a timeline for key activities that are needed to ensure zero by 30. Our findings reveal that rabies is grossly under-reported as only 998 human and 273 dog-suspected rabies cases were reported across Nigeria between 2017 and 2022. Our literature review also demonstrates a paucity of information on rabies in both human and animal health sectors. A total of 49 studies on dog rabies in Nigeria, with a predominance of reports from the North Central geopolitical region (48%, n = 23) were therefore included in this study. Currently, only 16.2% (n = 6/37) of Nigerian states have available data related to the estimated dog populations, the dog ownership rates, the vaccination status of dogs or the incidence of dog bites. Based on a dog-to-human ratio of 1:16.3, we estimated that the dog population in Nigeria was 12,969,368 (95% CI: 12,320,900-13,617,836). Thus, to attain herd immunity and dog rabies control in Nigeria, at least 9.1 million dogs must be vaccinated annually. Our review reveals that, despite the strengths and available opportunities to achieve rabies control in Nigeria by 2030, the weaknesses and challenges will make the attainment of zero by 30 very difficult or impossible. Nigeria's best-case scenario by the year 2030 is SARE stage 3-4 (control-elimination) out of 5. Otherwise, the rabies control programme might not surpass SARE stages 2-3. To attain zero by 30, Nigeria must re-strategize its current rabies control programme by funding and implementing the national strategic plan for rabies control, creating a rabies desk office in the 37 states (FCT inclusive), rigorously conducting mass vaccination campaigns, providing post-exposure prophylaxis, prioritizing mass enlightenment with a focus on responsible pet ownership and conduct baseline national rabies surveillance in the animal and human health sectors.

The Elephant in the Room: Racial Microaggressions and Implicit Bias in Surgical Training.

OBJECTIVE: The aim of this study was to examine the association between race, experience of microaggressions, and implicit bias in surgical training. BACKGROUND: There is persistent underrepresentation of specific racial and ethnic groups in the field of surgery. Prior research has demonstrated significant sex differences among those who experience microaggressions during training. However, little research has been conducted on the association between race and experiences of microaggressions and implicit bias among surgical trainees. METHODS: A 46-item survey was distributed to general surgery residents and residents of surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. The questions included general information/demographic data and information about experiencing, witnessing, and responding to microaggressions during surgical training. The primary outcome was the prevalence of microaggressions during surgical training by self-disclosed race. Secondary outcomes were predictors of and adverse effects of microaggressions. RESULTS: A total of 1624 resident responses were obtained. General surgery residents comprised 825 (50.8%) responses. The female-to-male ratio was nearly equal (815:809). The majority of respondents identified as non-Hispanic White (63.4%), of which 5.3% of residents identified as non-Hispanic Black, and 9.5% identified as Hispanic. Notably, 91.9% of non-Hispanic Black residents (n=79) experienced microaggressions. After adjustment for other demographics, non-Hispanic Black residents were more likely than non-Hispanic White residents to experience microaggressions [odds ratio (OR): 8.81, P <0.001]. Similar findings were observed among Asian/Pacific Islanders (OR: 5.77, P <0.001) and Hispanic residents (OR: 3.35, P <0.001). CONCLUSIONS: Race plays an important role in experiencing microaggressions and implicit bias. As the future of our specialty relies on the well-being of the pipeline, it is crucial that training programs and institutions are proactive in developing formal methods to address the bias experienced by residents.

Outcomes of Immediate Multistaged Abdominal Wall Reconstruction of Infected Mesh: Predictors of Surgical Site Complications and Hernia Recurrence.

BACKGROUND: Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection. METHODS: We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma. RESULTS: Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index (P = 0.006), bridge repair (P = 0.035), and postoperative surgical site infection (P = 0.005) were associated with hernia recurrence. CONCLUSION: Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.

Strengthening coordination and collaboration of one health approach for zoonotic diseases in Africa.

Despite the One Health progress made in some African countries in addressing zoonotic disease outbreaks, many still lack formal and funded One Health programs. Countries lack diagnostic capacity for zoonotic diseases, coordinated surveillance mechanisms, multisectoral response strategies and skilled workforce. With the devasting impacts of zoonotic disease outbreaks, recent epidemics have caused a loss of lives and negatively impacted the economy. Strengthening One Health approach across African Union (AU) Member States will improve the continent's ability and capacity to efficiently prevent, detect, and respond to emerging and re-emerging zoonotic diseases. The policy and practice changes needed to address zoonotic diseases require strong political commitment, financial investments, and institutionalised national One Health programs. The African Union endorses a One Health approach in which multiple sectors work jointly to raise awareness, gather credible data, implement programs, and promote evidence-based policy and practice in improve human, animal, and environmental health. The African Union working through its technical agencies set up an interagency multidisciplinary group "the One Health Coordinating Group on Zoonotic Diseases" to strengthen coordinated surveillance, prevention and control of zoonotic diseases on the continent. There is an urgent need to strengthen the coordination of One Health activities across the African continent. The African Union will leverage its unique political position on the continent to raise awareness, secure commitments, and influence policy at the head of state level. This manuscript highlights the opportunity to improve and strengthen One Health coordination and harmonisation of efforts through a continental strategy for zoonotic disease control.

A framework to improve retention of Black surgical trainees: A Society of Black Academic Surgeons white paper.

Attrition is high among surgical trainees, and six of ten trainees consider leaving their programs, with two ultimately leaving before completion of training. Given known historically and systemically rooted biases, Black surgical trainees are at high risk of attrition during residency training. With only 4.5% of all surgical trainees identifying as Black, underrepresentation among their peers can lend to misclassification of failure to assimilate as clinical incompetence. Furthermore, the disproportionate impact of ongoing socioeconomic crisis (e.g., COVID-19 pandemic, police brutality etc.) on Black trainees and their families confers additional challenges that may exacerbate attrition rates. Thus, attrition is a significant threat to medical workforce diversity and health equity. There is urgent need for surgical programs to develop proactive approaches to address attrition and the threat to the surgical workforce. In this Society of Black Academic Surgeons (SBAS) white paper, we provide a framework that promotes an open and inclusive environment conducive to the retention of Black surgical trainees, and continued progress towards attainment of health equity for racial and ethnic minorities in the United States.