BACKGROUND: This review aims to evaluate the effectiveness of extended reality-based training in surgical education. METHODS: This systematic review was conducted in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS: A total of 33 studies were included in the qualitative analysis. Nine studies evaluated the effectiveness of virtual reality-based training against no substitutional training. Seven studies looked at training for laparoscopic surgery, and the results were contradicting. Two studies focused on orthopedics training, and the outcomes were positive. Fourteen studies compared the outcomes of virtual reality-based training to conventional didactic teaching, all demonstrating superior outcomes for virtual reality-based training. Nine studies compared the outcomes of virtual reality simulation training to dry lab simulation training. The inferior outcomes of virtual reality simulation training were demonstrated by 5 studies for laparoscopic surgery, 1 study for arthroscopic procedures, 1 study for robotic surgery, and 1 study for dental procedures. One study found potential benefits of virtual reality simulation training on orthopedics surgeries. One study found virtual reality simulation training to be superior to cadaveric training, and 3 studies found augmented reality and virtual reality-based training to be comparable to supervised operative opportunities. CONCLUSION: Extended reality-based training is a potentially useful modality to serve as an adjunct to the current physical surgical training.

BACKGROUND: Investigating changes in sleep and fatigue metrics during intensive surgical and trauma skills training, this study explored the dynamic association between oculomotor metrics and fatigue. Specifically, alterations in these relations over extended stress exposure, the influence of time of day, and the impact of fatigue exposure on sleep metrics were examined. METHODS: Thirty-nine military medical students participated in 6 days of immersion, hyper-realistic, and high-stress experiential casualty training. Participants completed surveys assessing the state of sleepiness with oculomotor tests performed each morning and evening, analyzing eye movement and pupillary change to characterize fatigue. Participants wore Fitbit TM devices to measure overall time asleep and time in each sleep stage during the training. RESULTS: Fitbit data showed increased average minutes in rapid eye movement, deep sleep, and less time in light sleep from day 1 to day 4. The microsaccade peak velocity-to-displacement ratio exhibited a morning decrease but not in afternoon sessions, indicating repeated but temporary effects of accumulated fatigue. There were no findings regarding pupil reactivity to illumination changes. CONCLUSION: This study describes characteristics of fatigue measured by rapid and individually calibrated oculomotor tests. It demonstrates oculomotor relationships to fatigue in start-of-day testing, providing a direction for timing for optimal fatigue testing. These data suggest that improved sleep could signal resilience to fatigue during afternoon testing. Further investigation with more participants and longer duration is warranted. A deeper understanding of the interrelationships between training, sleep, and fatigue could improve surgical and military fitness.

BACKGROUND: Bariatric surgery is an effective intervention that causes a series of metabolic changes related to inflammatory processes; however, the variation of biomarkers related to these processes is not entirely understood. Our objective was to investigate the variation of modulation and expression of biomarkers associated with inflammation in patients who underwent bariatric surgery. METHODS: We searched the MEDLINE (via PubMed), EMBASE (via Elsevier), Cochrane Central Register of Controlled Trials, Latin American and Caribbean Literature on Health Sciences (via virtual health library), Cumulative Index to Nursing and Allied Health Literature (via EBSCO), Web of Science core collection, and Scopus (via Elsevier) databases, and the gray literature was examined from inception to January 2022. Three pairs of reviewers performed data screening, extraction, and quality assessment independently. Meta-analysis with random effects models was used for general, subgroup, and sensitivity analyses. The I2 statistic was used to assess heterogeneity between studies. RESULTS: In total, 96 articles were included in this systematic review; of these, 87 studies met the criteria for the meta-analysis, involving 3,533 participants. Five biomarkers were included in the meta-analysis (tumor necrosis factor alpha; interleukin 6; leptin; interleukin 1 beta, and lipopolysaccharides). Only leptin showed a significant decrease in the first month after surgery (mean difference -20.71; [95% confidence interval: -28.10 to -13.32, P < .0001; I2 = 66.7%), with moderate heterogeneity. The 12 months after surgery showed a significant decrease in tumor necrosis factor alpha (mean difference -0.89; [95% confidence interval: -1.37 to -0.42], P = .0002; I2 = 94.7%), interleukin 6 (mean difference -1.62; [95% confidence interval: -1.95 to -1.29], P < .0001; I2 = 94.9%), leptin (mean difference -28.63; [95% confidence interval: -34.02 to -23.25], P < .0001; I2 = 92.7%), and interleukin 1 beta (mean difference -2.46; [95% confidence interval: -4.23 to -0.68], P = .006; I2 = 98.3%), all with high heterogeneity. The type of surgery did not show significant differences for the biomarkers at the first month and 12 months, and the results have not changed with high-quality studies. In the 12-month measurement, variations in tumor necrosis factor alpha and leptin were associated with body mass index. CONCLUSION: The findings of this meta-analysis suggest that Roux-en-Y gastric bypass and sleeve gastrectomy bariatric surgeries are associated with a significant reduction in leptin at 1 month after bariatric surgical intervention and tumor necrosis factor alpha, leptin, and interleukin 1 beta after 12 months.

BACKGROUND: Numerous attempts have been made to identify risk factors for surgery complications, but few studies have identified accurate methods of predicting complex outcomes involving multiple complications. METHODS: We performed a prospective cohort study of general surgical inpatients who attended 4 regionally representative hospitals in China from January to June 2015 and January to June 2016. The risk factors were identified using logistic regression. A Bayesian network model, consisting of directed arcs and nodes, was used to analyze the relationships between risk factors and complications. Probability ratios for complications for a given node state relative to the baseline probability were calculated to quantify the potential effects of risk factors on complications or of complications on other complications. RESULTS: We recruited 19,223 participants and identified 21 nodes, representing 9 risk factors and 12 complications, and 55 direct relationships between these. Respiratory failure was at the center of the network, directly affected by 5 risk factors, and directly affected 7 complications. Cardiopulmonary resuscitation and sepsis or septic shock also directly affected death. The area under the receiver operating characteristic curve for the ability of the network to predict complications was >0.7. Notably, the probability of other severe complications or death significantly increased when a severe complication occurred. Most importantly, there was a 141-fold higher risk of death when cardiopulmonary resuscitation was required. CONCLUSION: We have created a Bayesian network that displays how risk factors affect complications and their interrelationships and permits the accurate prediction of complications and the creation of appropriate preventive guidelines.

BACKGROUND: Surgical site infection is one of the serious complications of transforaminal lumbar interbody fusion surgery, and many factors affect its occurrence. METHODS: A total of 1,277 patients who underwent transforaminal lumbar interbody fusion between 2018 and 2021 were enrolled in this study. Subsequently, 1,277 patients were randomly assigned to a training cohort (N = 958) and a validation cohort (N = 319) in a 3:1 ratio. We developed a nomogram according to the results of binary logistic regression analysis in the training cohort. The nomogram's predictive accuracy and discriminative ability were evaluated by calibration curve and receiver operating characteristic analysis. Decision curve analysis was performed to estimate the clinical value of our nomogram. RESULTS: In univariate and multivariate analysis, smoking, diabetes, intraoperative blood loss, American Society of Anesthesiologists class ≥III, serum calcium, albumin, and serum glucose were identified as significant independent predictors. The nomogram was developed using these independent predictors, which showed good diagnostic accuracy for surgical site infection of the training and validation cohorts. The calibration curves for the 2 cohorts showed optimal agreement between nomogram prediction and actual observation. The decision curve analysis of the nomogram model showed the great clinical use of the nomogram. CONCLUSION: The nomogram based on smoking, diabetes, intraoperative blood loss, American Society of Anesthesiologists class, serum calcium, albumin, and serum glucose has the potential as a clinically useful predictive tool of surgical site infection after transforaminal lumbar interbody fusion surgery. It is helpful to visualize the risk factors of surgical site infection.

OBJECTIVE: Acute lung injury (ALI) caused by sepsis is a life-threatening condition characterized by uncontrollable lung inflammation. The current study sought to investigate the mechanism of adipose-derived mesenchymal stem cell-derived exosomes (ADMSC-Exos) in attenuating sepsis-induced ALI through TGF-β secretion in macrophages. METHODS: Adipose-derived mesenchymal stem cell-derived exosomes (ADMSC-Exos) were extracted from ADMSCs and identified. Septic ALI mouse models were established via cecal ligation and puncture (CLP), followed by administration of ADMSC-Exos or sh-TGF-β lentiviral vector. Mouse macrophages (cell line RAW 264.7) were treated with lipopolysaccharide (LPS), co-cultured with Exos and splenic T cells, and transfected with TGF-β siRNA. The lung injury of CLP mice was evaluated, and levels of inflammatory indicators and macrophage markers were measured. The localization of macrophage markers and TGF-β was determined, and the level of TGF-β in lung tissues was measured. The effect of TGF-β knockdown on sepsis-induced ALI in CLP mice was evaluated, and the percentages of CD4+CD25+Foxp3+ Tregs in mononuclear cells/macrophages and Foxp3 levels in lung tissues/co-cultured splenic T cells were examined. RESULTS: ADMSC-Exos were found to alleviate sepsis-induced ALI, inhibit inflammatory responses, and induce macrophages to secrete TGF-β in CLP mice. TGF-β silencing reversed the alleviating effect of ADMSC-Exos on sepsis-induced ALI. ADMSC-Exos also increased the number of Tregs in the spleen of CLP mice and promoted M2 polarization and TGF-β secretion in LPS-induced macrophages. After knockdown of TGF-β in macrophages in the co-culture system, the number of Tregs decreased, suggesting that ADMSC-Exos increased the Treg number by promoting macrophages to secrete TGF-β. CONCLUSION: Our findings suggest ADMSC-Exos can effectively alleviate sepsis-induced ALI in CLP mice by promoting TGF-β secretion in macrophages.

BACKGROUND: More than 700 hospitals participate in the American College of Surgeons National Surgical Quality Improvement Program, but most pancreatectomies are performed in 165 centers participating in the pancreas procedure-targeted registry. We hypothesized that these hospitals ("targeted hospitals") might provide more specialized care than those not participating ("standard hospitals"). METHODS: The 2014 to 2019 pancreas-targeted and standard American College of Surgeons National Surgical Quality Improvement Program registry were reviewed regarding patient demographics, comorbidities, and perioperative outcomes using standard univariate and multivariable logistic regression analyses. Primary outcomes included 30-day mortality and serious morbidity. RESULTS: The registry included 30,357 pancreatoduodenectomies (80% in targeted hospitals) and 14,800 distal pancreatectomies (76% in targeted hospitals). Preoperative and intraoperative characteristics of patients treated at targeted versus standard hospitals were comparable. On multivariable analysis, pancreatoduodenectomies performed at targeted hospitals were associated with a 39% decrease in 30-day mortality (odds ratio, 0.61; 95% confidence interval, 0.50-0.75), 17% decrease in serious morbidity (odds ratio, 0.83; 95% confidence interval, 0.77-0.89), and 41% decrease in failure-to-rescue (odds ratio, 0.59; 95% confidence interval, 0.47-0.74). These differences did not apply to distal pancreatectomies. Participation in the targeted registry was associated with higher rates of optimal surgery for both pancreatoduodenectomy (odds ratio, 1.33; 95% confidence interval, 1.25-1.41) and distal pancreatectomy (odds ratio, 1.17; 95% confidence interval, 1.06-1.30). CONCLUSION: Mortality and failure-to-rescue rates after pancreatoduodenectomy in targeted hospitals were nearly half of rates in standard American College of Surgeons National Surgical Quality Improvement Program hospitals. Further research should delineate factors underlying this effect and highlight opportunities for improvement.

BACKGROUND: We examined differences in surgical intervention at minority-serving hospitals versus non-minority-serving hospitals among patients with early-stage hepatocellular carcinoma. We also investigated associations between surgical management and overall survival, stratified by minority-serving hospital status. METHODS: Patients with early-stage hepatocellular carcinoma, defined as cT1, were identified within the National Cancer Database (2004-2018). The primary outcome was surgical intervention (resection, ablation, or transplantation). The proportion of minority (non-Hispanic Black or Hispanic) patients treated at each facility was determined, and hospitals in the top decile were considered minority-serving hospitals. RESULTS: A total of 46,703 patients with early-stage hepatocellular carcinoma were identified, of whom 4,214 (9.0%) were treated at minority-serving hospitals. Patients treated at minority-serving hospitals were less likely to undergo surgical intervention than patients treated at non-minority-serving hospitals (odds ratio = 0.87, 95% confidence interval: 0.81-0.94). Minority patients treated at non-minority-serving hospitals were less likely to undergo surgical intervention than White patients (odds ratio = 0.86, 95% confidence interval: 0.82-0.90) and had a further associated decrease in the likelihood of surgical intervention when treated at minority-serving hospitals (odds ratio = 0.81, 95% confidence interval: 0.69-0.94). Regardless of minority-serving hospital status, surgery was associated with improved overall survival. There were no clinically meaningful differences in overall survival between White and minority patients who underwent surgery either at minority-serving hospitals or non-minority-serving hospitals. CONCLUSIONS: Patients with early-stage hepatocellular carcinoma had an associated decrease in the likelihood of surgical intervention when treated at minority-serving hospitals. Minority patients treated at minority-serving hospitals had an associated decrease in the likelihood of surgery, but to a lesser extent when treated at non-minority-serving hospitals. Surgery was associated with improved overall survival regardless of minority or minority-serving hospital status.

BACKGROUND: Resilience, or the ability to adapt to difficult or challenging life experiences, may be an important mediator in trauma recovery. The primary aim of this study was to describe resilience levels for trauma patients using the validated Connor-Davidson Resilience Scale. METHODS: Adult trauma patients admitted to a Level 1 trauma center (June 2022-August 2022) were surveyed at the time of admission and by phone between 2 weeks and 1 month after the original survey to obtain follow-up scores. We utilized the validated Connor-Davidson Resilience Scale score, a 25-question survey with 5 subfactors (Tenacity, Positive Outlook, Social Support, Problem Solving, and Meaning and Purpose). Each question was scored from 0 to 4 (maximum score 100, representing the highest resilience). Patient factors were collected from the electronic medical record and trauma health registry. Wilcoxon signed-rank test and multivariable linear regression were used to understand associations with Connor-Davidson Resilience Scale scores. RESULTS: We enrolled 98 patients. The median age was 50 years (interquartile range 32-67), and 74% were male sex. The baseline median Connor-Davidson Resilience Scale score on admission was 88 (interquartile range 81-94). Follow-up surveys (N = 64) showed a median score of 89.5 (80-90.5) (P = non-significant). No demographic variable was significantly associated with increasing baseline Connor-Davidson Resilience Scale score. Increased length of stay (β = 1.03), insurance (β = -7.50), and unknown race (β = 23.69) were correlated with follow-up Connor-Davidson Resilience Scale scores. The subfactor "Meaning and Purpose" decreased at follow-up but was not statistically significant (P = .05). CONCLUSION: Validated tools that can accurately distinguish variability in resilience scores are needed for the trauma patient population to understand its relationship with long-term patient health outcomes.

BACKGROUND: The aim of this study was to investigate the prognostic impact of postoperative infections in patients who underwent resection for biliary malignancy, including intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, distal cholangiocarcinoma, gallbladder carcinoma, and carcinoma of the ampulla of Vater. METHODS: This study was conducted in an 11-center retrospective cohort study. Patients with biliary tract cancer who underwent curative resection between April 2013 and March 2015 at 11 institutions in Japan were enrolled. We analyzed the prevalence of postoperative infection, infection-related factors, and prognostic factors. RESULTS: Of the total 290 cases, 33 were intrahepatic cholangiocarcinoma, 60 were perihilar cholangiocarcinoma, 120 were distal cholangiocarcinoma, 55 were gallbladder carcinoma, and 22 were carcinoma of the ampulla of Vater. Postoperative infectious complications, including remote infection, were observed in 146 patients (50.3%), and Clavien-Dindo ≥III in 115 patients (39.7%). Postoperative infections occurred more commonly in the patients who received pancreaticoduodenectomy and bile duct resection. Patients with infectious complications had a significantly poorer prognosis than those without (median overall survival 38 months vs 62 months, P = .046). In a diagnosis-specific analysis, although there was no correlation between infectious complications and overall survival in intrahepatic cholangiocarcinoma, perihilar cholangiocarcinoma, distal cholangiocarcinoma, and carcinoma of the ampulla of Vater, infectious complications were a significantly poor prognostic factor in gallbladder carcinoma (P = .031). CONCLUSION: Postoperative infection after surgery for biliary tract cancer commonly occurred, especially in patients who underwent pancreaticoduodenectomy and bile duct resection. Postoperative infection is relatively associated with the prognosis of patients with biliary malignancy, especially gallbladder carcinoma.

BACKGROUND: To maximize patient safety, surgical skills education is increasingly adopting simulation-based curricula for formative skills assessment and training. However, many standardized assessment tools rely on human raters for performance assessment, which is resource-intensive and subjective. Simulators that provide automated and objective metrics from sensor data can address this limitation. We present an instrumented bench suturing simulator, patterned after the clock face radial suturing model from the Fundamentals of Vascular Surgery, for automated and objective assessment of open suturing skills. METHODS: For this study, 97 participants (35 attending surgeons, 32 residents, and 30 novices) were recruited at national vascular conferences. Automated hand motion metrics, especially focusing on rotational motion analysis, were developed from the inertial measurement unit attached to participants' hands, and the proposed suite of metrics was used to differentiate between the skill levels of the 3 groups. RESULTS: Attendings' and residents' performances were found to be significantly different from novices for all metrics. Moreover, most of our novel metrics could successfully distinguish between finer skill differences between attending and resident groups. In contrast, traditional operative skill metrics, such as time and path length, were unable to distinguish attendings from residents. CONCLUSION: This study provides evidence for the effectiveness of rotational motion analysis in assessing suturing skills. The suite of inertial measurement unit-based hand motion metrics introduced in this study allows for the incorporation of hand movement data for suturing skill assessment.

BACKGROUND: The American Academy of Pediatrics published consensus guidelines advising observation of asymptomatic umbilical hernias until age 4 or 5, given unnecessary risks of early intervention and substantial practice variation. Yet, the impact of guidelines on early repair (age <4) or if certain groups remain at risk for avoidable intervention is unclear. METHODS: This retrospective study used data from children's hospitals participating in the Pediatric Health Information System database. Children aged 17 years and younger who underwent umbilical hernia repair from July 2017 to August 2022 were eligible for inclusion. Children with recurrent hernias, an emergency, or urgent presentation were excluded. An interrupted time series using segmented multivariable logistic regression estimated the association of guideline publication in November 2019 with the odds of guideline-adherent repair (age ≥4) after adjusting for sociodemographic characteristics and hospital-level random effects. RESULTS: 16,544 children underwent repair, of which 3,115 (18.8%) were children <4 years old. After adjustment, guideline publication was associated with an immediate increase in guideline-adherent repairs (odds ratio = 1.25 95% confidence interval = 1.05-1.49). The interrupted time series found that each month after publication was associated with a 2% increase in the odds of guideline-adherent repair (odds ratio = 1.02, 95% confidence interval = 1.01-1.03). Children with public insurance were nearly 20% less likely to receive guideline-adherent repair than privately insured children (odds ratio = 0.82, 95% confidence interval = 0.74-0.91). Children in the Midwest had lower odds of guideline-adherent repair (Midwest versus Northeast: odds ratio = 0.45. 95% confidence interval = 0.24-0.84). CONCLUSION: Guideline publication was associated with greater odds of guideline-adherent repair, yet public insurance coverage and Midwest location remain significant predictors of early repair against recommendations.