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Operative mortality is lower at hospitals with a high volume of certain surgical procedures. In this analysis of Medicare data, operative mortality declined for eight surgical procedures studied over a decade. Higher hospital volumes explained much of the decline for three of the operations. Fueled by a growing number of studies reporting inverse relationships between hospital volume and surgical mortality, 1 – 3 there was considerable interest in the United States during the previous decade in concentrating selected operations in high-volume hospitals. The Leapfrog Group, a consortium of large corporations and public agencies that purchase health care, has been among the most prominent advocates of volume-based referral. In 2000, it established minimum volume standards for several surgical procedures as part of a broader, value-based purchasing initiative. 4 Private payers and professional organizations in the United States have also established minimum volume standards as part of Centers of . . .

Urgent restoration of training is critical to the UK’s future surgical workforce

Surgery is the oldest oncological discipline and remains the cornerstone of treatment for most patients with cancer. However, the way surgery is used to treat cancer has evolved and outcomes continue to improve as a result of greater biological understanding, relentless technical innovation and a paradigm shift towards multimodal treatment. In this Perspectives, the authors discuss the developments in cancer surgery that have occurred over time and provide an overview of the key uses of surgery in the current era of multidisciplinary cancer care. Surgery is the oldest oncological discipline, dating back thousands of years. Prior to the advent of anaesthesia and antisepsis 150 years ago, only the brave, desperate, or ill-advised patient underwent surgery because cure rates were low, and morbidity and mortality high. However, since then, cancer surgery has flourished, driven by relentless technical innovation and research. Historically, the mantra of the cancer surgeon was that increasingly radical surgery would enhance cure rates. The past 50 years have seen a paradigm shift, with the realization that multimodal therapy, technological advances, and minimally invasive techniques can reduce the need for, or the detrimental effects of, radical surgery. Preservation of form, function, and quality of life, without compromising survival, is the new mantra. Today's surgeons, no longer the uneducated technicians of history, are highly trained medical professionals and together with oncologists, radiologists, scientists, anaesthetists and nurses, have made cancer surgeries routine, safe, and highly effective. This article will review the major advances that have underpinned this evolution.

The COVID-19 pandemic has affected every aspect of medical care, including surgical treatment. It is critical to understand the association of government policies and infection burden with surgical access across the United States. To describe the change in surgical procedure volume in the US after the government-suggested shutdown and subsequent peak surge in volume of patients with COVID-19. This retrospective cohort study was conducted using administrative claims from a nationwide health care technology clearinghouse. Claims from pediatric and adult patients undergoing surgical procedures in 49 US states within the Change Healthcare network of health care institutions were used. Surgical procedure volume during the 2020 initial COVID-19-related shutdown and subsequent fall and winter infection surge were compared with volume in 2019. Data were analyzed from November 2020 through July 2021. 2020 policies to curtail elective surgical procedures and the incidence rate of patients with COVID-19. Incidence rate ratios (IRRs) were estimated from a Poisson regression comparing total procedure counts during the initial shutdown (March 15 to May 2, 2020) and subsequent COVID-19 surge (October 22, 2020-January 31, 2021) with corresponding 2019 dates. Surgical procedures were analyzed by 11 major procedure categories, 25 subcategories, and 12 exemplar operative procedures along a spectrum of elective to emergency indications. A total of 13 108 567 surgical procedures were identified from January 1, 2019, through January 30, 2021, based on 3498 Current Procedural Terminology (CPT) codes. This included 6 651 921 procedures in 2019 (3 516 569 procedures among women [52.9%]; 613 192 procedures among children [9.2%]; and 1 987 397 procedures among patients aged ≥65 years [29.9%]) and 5 973 573 procedures in 2020 (3 156 240 procedures among women [52.8%]; 482 637 procedures among children [8.1%]; and 1 806 074 procedures among patients aged ≥65 years [30.2%]). The total number of procedures during the initial shutdown period and its corresponding period in 2019 (ie, epidemiological weeks 12-18) decreased from 905 444 procedures in 2019 to 458 469 procedures in 2020, for an IRR of 0.52 (95% CI, 0.44 to 0.60; P < .001) with a decrease of 48.0%. There was a decrease in surgical procedure volume across all major categories compared with corresponding weeks in 2019. During the initial shutdown, otolaryngology (ENT) procedures (IRR, 0.30; 95% CI, 0.13 to 0.46; P < .001) and cataract procedures (IRR, 0.11; 95% CI, -0.11 to 0.32; P = .03) decreased the most among major categories. Organ transplants and cesarean deliveries did not differ from the 2019 baseline. After the initial shutdown, during the ensuing COVID-19 surge, surgical procedure volumes rebounded to 2019 levels (IRR, 0.97; 95% CI, 0.95 to 1.00; P = .10) except for ENT procedures (IRR, 0.70; 95% CI, 0.65 to 0.75; P < .001). There was a correlation between state volumes of patients with COVID-19 and surgical procedure volume during the initial shutdown (r = -0.00025; 95% CI, -0.0042 to -0.0009; P = .003), but there was no correlation during the COVID-19 surge (r = -0.00034; 95% CI, -0.0075 to 0.00007; P = .11). This study found that the initial shutdown period in March through April 2020, was associated with a decrease in surgical procedure volume to nearly half of baseline rates. After the reopening, the rate of surgical procedures rebounded to 2019 levels, and this trend was maintained throughout the peak burden of patients with COVID-19 in fall and winter; these findings suggest that after initial adaptation, health systems appeared to be able to self-regulate and function at prepandemic capacity.

Analyzing general surgeons’ operative case mix can provide an update on contemporary practice patterns and inform pragmatic residency training. We performed a retrospective cohort study of general surgeons in Florida, Iowa, and Maryland, 2016–2020. Cases were identified using billing codes. The Cochran-Armitage test of trends was used to evaluate the proportion of practice devoted to specific case types and operative setting over time. General surgeons (n ​= ​1300) performed 1,287,745 cases. The mean (±SD) annual volume per surgeon for all procedures was 356 (±250), with 198 (±152) general surgery operations, 57 (±142) endoscopic procedures, and 101 (±109) other cases. On average, surgeons operated on 7.1 (±2.6) different organ systems. Trends toward a lower proportion of general surgery operations, and a greater proportion of subspecialty procedures and surgery in the outpatient setting over time were demonstrated (p ​< ​0.001). The practice pattern of the general surgeon continues to be heterogeneous, reflecting the persistent need for a broad training paradigm that permits specialization. [Display omitted] •Contemporary general surgery case mix remains heterogeneous with a continuing trend toward the outpatient setting.•Surgical setting selected by the surgeon, whether inpatient vs outpatient, differs by hospital characteristics.•Graduate surgical education should use data on independently practicing surgeons' practices to inform surgical training.

Introduction Covid-19 has had a significant impact on all aspects of health care. We aimed to characterise the trends in emergency general surgery at a district general hospital in Scotland. Methods A prospective cohort study was performed from 23/03/20 to 07/05/20. All emergency general surgery patients were included. Demographics, diagnosis and management were recorded along with Covid-19 testing and results. Thirty-day mortality and readmission rates were also noted. Similar data were collected on patients admitted during the same period in 2019 to allow for comparison. Results A total of 294 patients were included. There was a 58.3 per cent reduction in admissions when comparing 2020 with 2019 (85 vs 209); however, there was no difference in age (53.2 vs 57.2 years, p  = 0.169) or length of stay (4.8 vs 3.7 days, p  = 0.133). During 2020, the diagnosis of appendicitis increased (4.3 vs 18.8 per cent, p  = < 0.05) as did severity (0 per cent > grade 1 vs 58.3 per cent > grade 1, p  = < 0.05). The proportion of patients undergoing surgery increased (19.1 vs 42.3 per cent, p  = < 0.05) as did the mean operating time (102.4 vs 145.7 min, p  = < 0.05). Surgery was performed in 1 confirmed and 1 suspected Covid-19 patient. The latter died within 30 days. There were no 30-day readmissions with Covid-19 symptoms. Conclusion Covid-19 has significantly impacted the number of admissions to emergency general surgery. However, emergency operating continues to be needed at pre-Covid-19 levels and as such provisions need to be made to facilitate this.

Newer regional anesthesia techniques and minimally invasive surgeries have yielded decreased postoperative pain scores, potentially leading to decreased need for perioperative epidural analgesia. Limited literature is available on trends in usage rates of epidurals. The objective of this study was to identify trends in perioperative epidural analgesia rates among multiple fields of surgery. All patients undergoing general, thoracic, urologic, plastic, vascular, orthopedic, or gynecological surgery in 2014–2020 were included from the National Surgical Quality Improvement Program database of over 700 hospitals in the U.S. and 11 different countries. Annual trends in epidural analgesia for all surgeries and each surgical specialty were assessed by mixed effects multivariable logistic regression. The odds ratios (OR) and 99 % confidence intervals (CI) were reported. There were 3,111,435 patients from 2014 to 2020 that were included in the final analysis, in which 107,209 (3.4 %) received perioperative epidural analgesia. Among all surgeries combined, epidural use throughout the study period decreased (OR 0.98 per year, 99 % CI 0.97–0.98, P < 0.001). When only analyzing the surgeries with the top 5 most frequent epidural use per specialty, there was no statistically significant trend in epidural utilization (OR 0.99 per year, 99 % CI 0.99–1.00, P = 0.09). However, there was an increasing trend in epidural utilization in general surgery (OR 1.05 per year, 99 % CI 1.03–1.07, P < 0.001) and vascular surgery (OR 1.08 per year, 99 % CI 1.05–1.10, P < 0.001). Rates of perioperative epidural analgesia use has decreased in recent years overall, however, among surgeries within the general surgery and vascular surgery specialty, utilization has increased for procedures that have the highest rates of usage. •Based on data mainly from the U.S., perioperative epidural usage has decreased from 2014 to 2020.•Epidural usage has increased in open vascular and general surgeries from 2014 to 2020.•General surgery procedures had the highest rate of epidural utilization

Incisional hernia (IH) represents a complex and costly surgical complication. We aim to address trends in open surgery to better understand potential drivers of hernia risk. Using the 2009–2013 NIS, a cross-sectional review of hospital discharges associated with an open abdominal surgery was performed. Between 2009 and 2013, there were nearly 10 million discharges associated with an open abdominal surgery. Overall, there were 2,140,616 patients receiving open surgery in 2009, decreasing to 1,760,549 in 2013 (18% decrease, p < 0.001). Open hernia procedures increased from 37,325 patients in 2009 to 41,845 in 2013 (12% increase, p = 0.001). The most prevalent comorbidities within this population included uncomplicated hypertension (25.26%), chronic pulmonary diseases (13.52%), obesity (10.24%), uncomplicated diabetes (11.06%), and depression (10.72%). Our analysis allowed for a unique view of surgical trends, health care population dynamics, and an opportunity to use evidence-driven analytics in the understanding of IH. •This study assesses the total number of open surgeries publicly available through NIS from 2009 to 2013.•The prevalence of incisional hernia repair available in this same database from 2009 to 2013.•A keen focus on comorbidities associated with each discharge grouping.•Open surgeries are decreasing across specialties, while incisional hernia repair increases.•An epidemiologic scope of open surgical discharges in the United States.

In recognition of this fact, the Chinese government has made notable recent efforts to standardise surgical training programmes, as part of the National Health and Family Planning Commission's (NHFPC) complete set of model residency training programmes.2 Although the effort is laudable, the lack of credible mandatory minimums for procedures done, and of clear quality assurance systems, has left a major training gap unaddressed. Taking cataract surgery as an example, a recent study that included some of China's best known eye hospitals showed that mainland Chinese ophthalmology residents had undertaken a median of zero independent cataract operations during their training, compared with 100 cases for trainees in the Hong Kong Special Administrative Region (HKSAR) over a similar period.3 Differences in national requirements partly explain this finding: the current minimum standard for cataract surgeries is 100 cases by the completion of residency training in HKSAR,4 86 in the USA,5 120 in Singapore,6 and 350 in the UK,7 whereas the required number of cases for residents in training in China is only 15 according to regulations recently published by the Chinese NHFPC.8 About 90% of US ophthalmology residents exceed the national target,9 which does not seem to be the case in China.3 Differing approaches to enforcement of existing standards also appear to play a role: in the USA,10 HKSAR,11 and other countries, programmes not providing adequate training for residents risk losing accreditation, but the same consequences do not generally exist in China.