Ethical Considerations in the Interhospital Transfer of Patients.

Background: For very-rare cancers such as pheochromocytoma and paraganglioma (PPGL), center-level case volume is uniformly low, rendering the traditional volume–outcome paradigm uninformative. This study examines whether cancer programs’ institutional resources, after adjusting for tumor-specific case volume, impact overall survival (OS) after surgery. Methods: The 2004–2021 National Cancer Database was queried for patients with a diagnosis of PPGL with malignant potential. Demographics, clinicopathologic characteristics, socioeconomic status, and treatment and survival variables—together with program resource tier (high resource = Academic/Research + Comprehensive Community Cancer Programs; low resource = Community Cancer + Integrated Network Programs), were extracted. IPW-Cox proportional hazard model and survival analysis were performed. Results: 1306 patients were identified, of whom 1066 (81.6%) were treated at high-resource programs. Mean age was 59.0 years and 55.1% were female (n = 719). Median follow-up was 61.7 months (maximum 207 months). Mortality was 28.3% (n = 278). Age, race, median income, tumor size, and surgical approach did not differ by resource tier. Patients treated at high- vs. low-resource programs differed by Charlson– Deyo score (p = 0.008), gender (p = 0.033), insurance status (p = 0.004), and distance traveled to facility (p < 0.001). On adjusted survival analysis, treatment at a high-resource program was associated with improved OS (HR = 0.64, p = 0.043) and a mean survival advantage of 23 months (p = 0.009) vs. a low-resource program. Age (HR = 1.03), tumor size >10 cm (HR = 4.18), and metastasis (HR = 4.17) independently predicted worse OS. Conclusions: Despite uniformly low PPGL case volumes nationally, treatment at high-resource cancer programs was associated with a 23-month longer mean survival and a 36% lower risk of death compared with low-resource cancer programs. Further studies are needed to identify the specific institutional factors that drive this survival advantage in rare cancers.

CENTRALIZATION OF CARE FOR COMPLEX ENDOVASCULAR AORTIC ANEURYSM REPAIR.

The Guangzhou Arbitration Commission (GZAC) has played a central role in the modernization and internationalization of commercial arbitration in China since its establishment in 1995. Strategically located within the Guangdong–Hong Kong–Macao Greater Bay Area, GZAC has positioned itself as one of the country’s leading arbitral institutions, ranking first nationally in case volume and sectoral diversity. Through innovative digital platforms and the establishment of specialized arbitration courts, GZAC has set a precedent in efficiency, technological integration, and accessibility in arbitration proceedings. Within the BRICS framework, GZAC stands out as a key institutional actor, spearheading the BRICS Joint Arbitration Center Mechanism in collaboration with prominent institutions from Russia, India, Brazil, and South Africa. The 2025 Moscow meeting of the International Expert Committee marked a milestone in advancing multipolar legal governance, emphasizing cooperation, digital transformation, and capacity-building. This report details GZAC’s historical development, its institutional mission, and its strategic influence in shaping a global arbitration agenda under BRICS leadership. The document emphasizes how GZAC’s initiatives could help build a multipolar arbitration system that addresses current economic and legal challenges.

Despite the continued evolution of endovascular therapy (EVT), microsurgery will remain not only a viable option for aneurysm management into the foreseeable future, but for many aneurysms, the preferred treatment. However, reduction in surgical case volume in favor of EVT now represents a systemic threat to surgical proficiency by drastically reducing case volumes and creating a training challenge for the next generation, thereby degrading the proficiency of future surgeons. Surgeons who can safely and effectively manage the aneurysms for which surgery remains the superior or only option are at risk of extinction. This review addresses this critical issue as we reach an inflection point in the history of cerebrovascular surgery. The evidence to support EVT or surgical management of aneurysms is critically reviewed in the context of equipoise, a genuine state of uncertainty regarding the superiority of one therapeutic modality over another. This review is not an argument against the immense value of EVT, which has saved countless lives and remains the optimal treatment for many patients. Rather, it is a call for balance, for a recalibration of clinical equipoise, and for the preservation of a complete and robust therapeutic armamentarium.

New integrated plastic surgery residency programs are needed to meet the ongoing demand for practicing plastic surgeons in the United States. This study assessed surgical data before and after the start of a new residency program. This should help guide expectations for plastic surgery groups interested in establishing a residency and will also provide objective data to aid conversations between the department departments and their hosting hospital administration. All surgical cases at an academic medical center from July 2014 to June 2022 were retrospectively collected. Cases were divided into preresidency and postresidency periods. All cases were assigned a case type, complexity, and free flap designation. Metrics were analyzed for each period and adjusted per surgeon full-time equivalent. Case volume peaked during the final study year (2021-2022) at 272 cases per surgeon full-time equivalent per year. Case variety increased, with notable growth in gender affirmation and adult craniofacial trauma reconstruction. Routine reconstructive breast and body contouring cases declined. There was a significant increase in cases involving multiple free flaps within the same encounter. Complexity had been declining over time prior to the start of the residency and subsequently increased steadily after the start of the residency. The start of a new integrated plastic surgery residency had a rejuvenating effect on faculty practice that had previously been trending toward routine. As the demand for plastic surgery residency positions increases, this single-program experience may help guide expectations for departments seeking to begin a new program.

Learning process of transoral robotic surgery for head and neck cancers: a scoping review.

The Current Practice of Laparoscopically Assisted Anorectoplasty for Male Patients - An International Pediatric Endosurgery Group Survey.

Background: Orthoplastics represents a collaborative interface between plastic and orthopaedic surgery, focused on the reconstruction of complex limb injuries. Despite its increasing clinical importance, there is limited literature assessing orthoplastic exposure within plastic surgery and orthopaedic training programmes. This review aims to evaluate training patterns and trainee exposure to orthoplastic procedures. Methods: A literature review was conducted using PubMed, limited to the last ten years (2015–2025). MeSH terms included “orthoplastic,” “plastic surgery,” “orthopaedic surgery,” and “trainee exposure.” Studies assessing operative exposure, educational experiences, or training outcomes in orthoplastic or orthoplastic-type settings were included. Results: Fifteen PubMed-indexed articles met the search criteria. Key findings include: Mean orthoplastic-type cases per plastic surgery resident increased from 168.2 to 189.2 between 2011–2022, with peripheral nerve repairs rising 73 %. Plastic surgery residents consistently had higher hand and trauma case volumes than orthopaedic residents (e.g., total hand cases: 412 vs 247 respectively). Orthopaedic residents performed more trauma cases (mean: 133.2 vs 54.5 for plastic residents) but had limited exposure to nerve repair and micro-surgical procedures. Integrated orthoplastic services significantly increased operative exposure for both specialties (mean hand cases from 218 to 295). Conclusions: Over the past decade, orthoplastic exposure for surgical residents has increased but remains inconsistent. These findings highlight the need for structured, multidisciplinary rotations to standardise training and enhance competence in limb reconstruction across plastic surgery and orthopaedic programmes. Future study could involve a UK-based national survey to scope surgical trainees’ attitudes towards the integration of orthoplastics within the general surgical training pathways.

A quality improvement project was conducted to improve operating room (OR) access and utilization for elective ophthalmic cases at a university-affiliated eye center. This prospective, interventional case series assessed OR utilization across three ORs during a baseline 3-month period. Case scheduling protocols were reviewed, and key drivers of inefficiency were identified. Targeted interventions were implemented to address these barriers. During the baseline period, a mean of 290 surgeries were performed monthly. Scheduling delays were attributed to the lack of standardized order forms for special preoperative/operative needs, untimely completion of special preoperative tests, poor communication regarding open OR times, and inadequate enforcement of an established 14-day block time release. Following interventions, OR utilization increased by 20% and average monthly case volume rose to 350, adding approximately 60 surgeries per month. These improvements were accompanied by a more than twofold increase in use of the standardized EPIC surgical order with laterality (from 39 to 97 cases per month), demonstrating measurable adoption of workflow changes. Targeted, multidisciplinary interventions improved OR utilization by 20%. Quality improvement projects enhance patient access and optimize the use of institutional resources.

Intravenous sedation (IVS) is widely used in office-based esthetic surgery, yet large-scale safety data from private clinics are scarce. This study quantified IVS utilization and evaluated perioperative safety in a high-volume Japanese cosmetic center. A retrospective review was conducted of all consecutive procedures performed under IVS between November 2020 and December 2024 at a single clinic. Eligibility was restricted to American Society of Anesthesiologists (ASA) class I-II patients. Propofol was the first-line sedative; midazolam was substituted for documented egg or soy allergy. Standard monitoring (ECG, noninvasive blood pressure, SpO2 alarm at 90 %) and a target Modified Observer's Assessment of Alertness/Sedation (MOAA/S) score of 2-3 were employed. Primary endpoints were major cardiopulmonary events (unplanned intubation, cardiac arrest). Secondary endpoints comprised intra-operative antihypertensive therapy, elective termination of sedation owing to paradoxical agitation, prolonged recovery (> 30min to discharge readiness), and unplanned admission RESULTS: A total of 4,397 IVS procedures were analyzed (female 89.7%, median age 39 years). Annual case volume rose from 41 (2020) to 1,753 (2024); combined procedures increased from 6.5 to 86.5 % over the same period. Propofol was used in 4,366 cases (99.3%); midazolam was administered in 31 allergy-screened cases (0.7%). No major cardiopulmonary events occurred (0%; 95% CI 0.00-0.08). Hypertensive episodes treated with intravenous nicardipine were observed in 44 cases (1.0%); no patient required supplemental oxygen. Sedation was electively discontinued for paradoxical agitation in 24 cases (0.55%). Prolonged recovery was recorded in 75 cases (1.7%); all patients were discharged on the same day. No unplanned admissions occurred. Among 4,397 office-based esthetic procedures, IVS directed by non-anesthesiologist surgeons achieved a major complication rate of zero and a low incidence of minor events. Strict ASA I-II selection, continuous physiologic monitoring, and a weight-adjusted depth titration protocol can provide international-level safety in a private outpatient setting. Multicenter prospective studies are warranted to validate these findings and refine recovery benchmarks. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

BackgroundRecent studies suggest that general surgery (GS) residents perform more operations related to their future specialty compared with their peers. In this multi-institutional study, we examined the process of early specialization among GS residents pursuing a career in vascular surgery (VS).MethodsData from the US Resident OPerative Experience (ROPE) Consortium, comprising 20 Accreditation Council for Graduate Medical Education (ACGME)-accredited GS residency programs across the United States, were queried. Case volume and type were compared between GS residents pursuing vs fellowship and all other residents. Effect size was evaluated using Cohen's d statistic. Effect size was considered large if d > 0.8, moderate if 0.5 ≤ d < 0.8, small if 0.2 ≤ d < 0.5, and inconsequential if d < 0.2.ResultsA total of 1343 GS residents graduated from 2010-2020 across all programs participating in ROPE, of which 135 (10.1%) pursued vs fellowship. Total major vascular case volume was significantly greater among residents pursuing vs fellowship (138 [100-207] vs 100 [80-139], P < 0.0001) with a large effect size (d = 1.81). Vascular cases reported in a surgeon chief role (27 [9-53] vs 10 [2-29], P < 0.0001, d = 0.76, moderate effect) and surgeon junior role (107 [79-154] vs 88 [62-118], P < 0.0001, d = 1.00, large effect) were also greater among GS residents pursing a vs specialty. Nearly all vascular operative categories demonstrated similar trends (P < 0.01 each).ConclusionsGS residents pursuing a vs fellowship perform more vascular cases compared with their peers. Given the differences in both surgeon chief and surgeon junior roles, career focus may begin as early as the junior resident years.

Introduction: Pancreatico-duodenectomy (PD) remains one of the most complex abdominal surgeries, and pancreatico-jejunostomy (PJ) fistula is its most critical postoperative complication. In efforts to reduce the incidence of postoperative pancreatic fistula (POPF), several PJ techniques and adjuncts, including stents, have been recommended. This article presents data from an international survey regarding PJ methods, the use of pancreatic stents, and their correlation with POPF rates from surgical centers worldwide. Methods: A nine-item online questionnaire was sent globally through social networks, individual mailing lists, and the ASHBPS mailing list. Data were analyzed through the Student’s t-test (two-tailed, unequal variance). A p-value &lt; 0.05 was considered to be statistically significant. Results: A total of 122 units of pancreatic surgery from 26 countries distributed across five continents responded to the survey. Most centers performed less than 50 PDs a year, preferred a duct-to-mucosa PJ, and employed a stent routinely. Mean POPF grade B and C incidences were lower in high-volume (15.24% ± 7.29 and 3.95% ± 2.39) and in PJ stent-using centers (16.25% ± 8.7 and 5.37% ± 7.49). Conclusions: Institutional case volume and stent usage are more crucial determinants of POPF incidence than the PJ technique itself. Centralization and standardization of PD procedures are related to reductions in major fistula rates.

Introduction: Emergency physicians can use point-of-care ultrasound (POCUS) to identify lymph nodes in certain clinical scenarios, and advanced users can determine significant information (such as concerns for malignancy or differentiating them from abscesses for incision and drainage) based on a large volume of literature and images associated with those pathologies. However, current literature does not contain a similar volume of images and cases of suppurative lymph nodes, or buboes, limiting the ability to make the diagnosis sonographically at the bedside. Case Report: We report on a man who presented to the emergency department (ED) with a worsening inguinal mass that changed size with positioning, as well as a 20-pound weight loss occurring over the course of a month. Point-of-care ultrasound of the mass was concerning for a necrotic suppurative lymph node, which was further evaluated with cross-sectional imaging. The patient was admitted for a biopsy to rule out malignancy. He was discharged with serologies for Bartonella henselae pending, which later returned positive. The patient was then switched to azithromycin with significant improvement of his symptoms. Conclusion: As POCUS becomes the modality of choice for rapid assessment of soft tissue masses in the ED, familiarity with less common variants of soft tissue infections such as buboes can help with medical decision-making, risk stratification, and further workup. This sonographic description of a bubo caused by a common zoonotic infection will enable clinicians to familiarize themselves with their appearance.

Robotic surgery has revolutionized minimally invasive procedures by integrating advanced technology and improving outcomes. While adoption is increasing in East Asia, nationwide analyses across surgical specialties are limited. This study presents a 14-year analysis (2011-2024) of robotic surgery in Taiwan to elucidate trends on a national level and to provide insights to guide future surgical development and innovation. Data were collected from the Taiwan National Health Insurance Research Database from January 2011 to December 2024. Key metrics included the number and growth of certified robotic surgeons and the distribution of robotic surgical cases by specialty. Statistics with a focus on trend analysis were examined using Microsoft Excel® (Microsoft 365). Between 2011 and 2024, Taiwan saw a 13-fold increase (from 6 to 78) in da Vinci system installations and a rise in certified robotic surgeons from 38 to 697. Robotic case volume increased 23-fold (from 732 to 16,770). Urology remained dominant (43.1%), followed by gynecology (22.3%), general surgery (10.3%) and colorectal surgery (8.7%). Emerging adoption in otorhinolaryngology (8.0%), thoracic surgery (5.1%), and cardiovascular surgery (2.5%) reflect growing confidence in robotics for complex, high-risk procedures. These trends underscore Taiwan's expanding multidisciplinary integration of robotic surgery. This analysis highlights the evolution of robotic surgery in Taiwan, exemplifying broader innovation within East Asia. Robotic surgery remains promising across specialties, and ongoing technological integration and structured training are needed to sustain and expand its clinical impact.

Orthopaedic surgery is rapidly undergoing a technological transformation, driven by the integration of digital navigation, computer-assisted planning, and robotic systems. Robotic surgical systems are primarily used in knee and hip arthroplasty, as well as spinal surgery, with the goals of improving implant placement accuracy, reducing complication rates, and enhancing patient safety. These technologies have an impact on operation duration, error rates, and learning curves depending on the surgeon’s level of experience. However, high capital investment, maintenance costs, and consumables mean that cost-effectiveness is closely linked to case volume. Thus, the economic sustainability of robotic systems depends not only on technological efficiency but also on high procedure volume, appropriate reimbursement policies, and interdisciplinary operational integration. From an ethical and legal perspective, the spread of robotic surgery has brought new issues to the fore, such as responsibility sharing, transparency of AI-assisted decision systems, data security, and informed consent processes. In terms of clinical management, safe and effective implementation of robotic surgery requires standardized training programs for surgeons and teams, ongoing technical support, and clear, understandable policies and regulations. This review examines orthopaedic robotic surgery in terms of clinical efficacy, economic evaluation, and management, aiming to propose a holistic approach for the safe, ethical, and financially sustainable integration of technology into healthcare systems.

A framework for Surgical Quality Assurance (SQA) in randomized controlled trials in gastrointestinal surgery: an international Delphi consensus study

Military plastic surgeons play a critical role in the care and rehabilitation of wounded servicemembers. However, the ability of military plastic surgeons to maintain a robust reconstructive skill set within military treatment facilities (MTFs) is often hampered by a narrow case mix and low case volume. We conducted this study to evaluate how integration of a targeted military-civilian partnership (MCP) impacted an MTF-based plastic surgery practice. Beginning in March 2020, MTF-assigned plastic surgeons expanded their practice through a targeted MCP with a civilian cancer center, whereby military plastic surgeons provided reconstructive care to civilian patients. We obtained clinical workload data through the billing offices at the MCP and comparable offices within the MTF. The primary outcomes measured were the volume of operative procedures and the Joint Knowledge, Skills, and Ability (JKSA) scores related to the clinical workload. Outcomes were standardized to surgeon-months to adjust for variations in surgeon assignment time and then compared between the pre-intervention period (October 2016-February 2020) and the post-intervention period (March 2020-December 2022). Throughout the study period, five plastic surgeons contributed 187 surgeon-months at the MTF, spanning before (103 surgeon-months) and after (84 surgeon-months) the intervention. After MCP integration, military plastic surgeons demonstrated a significant increase in procedural volume, with an average of 33.3 procedures per surgeon-month compared to 16.3 before intervention (P < .001). Additionally, there was a substantial rise in the readiness value of the work being performed, as reflected by the JKSA points generated per surgeon-month (108.0 points vs 374.0 points, P < .001). The proportion of operative procedures yielding JKSA points also improved, increasing from 75.2% to 92.4% (P < .001). Notably, several lessons learned were identified to better support MCP integration into MTF based practices including the need for local infrastructure to support these advancements. Military-civilian partnerships are essential for military plastic surgeons to sustain the advanced reconstructive skills necessary to treat our nation's wounded service members. Further efforts are necessary to identify best practices in MCP oversight and execution.

Robotic surgery in Ireland: national governance framework and a guide to good practice.

Rhinoplasty is an ergonomically demanding procedure that subjects surgeons to prolonged unfavorable postures and repetitive fine motor movements, increasing the risk of work-related musculoskeletal disorders (WRMDs). Nevertheless, ergonomic awareness and training in rhinoplasty remain limited. To evaluate the prevalence of WRMDs among rhinoplasty surgeons and to assess ergonomic factors, training, and attitudes toward strategies to improve well-being and career longevity. A 36-item electronic survey was distributed to members of the Evidence-Based Rhinoplasty Research Group (Feb-May 2025) to gather demographic, professional, and ergonomic data, including Likert-scale assessments of comfort and strain during rhinoplasty. A total of 109 consultant surgeons completed the survey. Mean comfort and strain scores were 6.7 ± 1.7 and 5.2 ± 2.3, respectively. 72% experienced discomfort (mainly neck, shoulders, lower back), with greater experience correlating with better scores (p < 0.05). No significant differences were observed with gender, body-mass-index, height, average duration of each rhinoplasty, weekly time spent on rhinoplasty, or the use of headlights or loupes. Only 5.3% had received formal ergonomics training; however, 81.4% expressed interest in ergonomic assessments, and 93.8% believed exercise benefits career longevity. WRMDs are highly prevalent among rhinoplasty surgeons. Comfort and strain appear more related to posture, case volume, and cumulative experience than to specific instruments or techniques. Despite the prevalence and impact of these symptoms, ergonomic training remains rare, although interest is high. Targeted interventions-such as optimizing operating room setup, promoting intraoperative microbreaks, and encouraging physical exercise-are essential to reduce discomfort and support long-term career sustainability.