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Surgery_Schwartz_13702 | Surgery_Schwartz | to foster an envi-ronment of creativity and innovation necessary to generate new ideas for solving some of the most vexing problems in global health. For example, some academic collabora-tive programs introduce medical, engineering, and business students to the fascinating world of medical device innova-tion focusing on a variety of communities with very limited resources.181,182 Other academic endeavors include global surgery resident rotations, fellowships, journal clubs, classes (locally and online), certificates, Masters of Public Health, bilateral exchange programs, and a variety of educational, research, and entrepreneurial meetings (local, national, and international). Many of these activities provide opportuni-ties for collaborative scholarly work (journal publications, books, book chapters, films, grants, research trials) that pres-ent new avenues for academic advancement supporting both colleagues from abroad as well as the home institution. More importantly, Ministries of | Surgery_Schwartz. to foster an envi-ronment of creativity and innovation necessary to generate new ideas for solving some of the most vexing problems in global health. For example, some academic collabora-tive programs introduce medical, engineering, and business students to the fascinating world of medical device innova-tion focusing on a variety of communities with very limited resources.181,182 Other academic endeavors include global surgery resident rotations, fellowships, journal clubs, classes (locally and online), certificates, Masters of Public Health, bilateral exchange programs, and a variety of educational, research, and entrepreneurial meetings (local, national, and international). Many of these activities provide opportuni-ties for collaborative scholarly work (journal publications, books, book chapters, films, grants, research trials) that pres-ent new avenues for academic advancement supporting both colleagues from abroad as well as the home institution. More importantly, Ministries of | [
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Surgery_Schwartz_13703 | Surgery_Schwartz | chapters, films, grants, research trials) that pres-ent new avenues for academic advancement supporting both colleagues from abroad as well as the home institution. More importantly, Ministries of Health are responding to results of these scholarly works by designing policies that include surgi-cal care in their countrywide health plans.Partnering academic programs from high-income coun-tries with LMICs and/or with NGOs provides opportuni-ties for collaboration183 (Box: Academic Global Surgery 13Global surgery engagementsLEVEL OF INTEGRATIONAssociationAllianceCollaborationPartnership+–Figure 49-33. Training outcomes from NGO/academic partner-ship. (Reproduced with permission from IVUmed and Intermoun-tain Healthcare.)Academic Global Surgery PartnershipsA. Rwanda Human Resources for Health (HRH) ProgramThe Rwanda Human Resources for Health (HRH) program is an ambitious 7-year long program of the Ministry of Health (MOH) of Rwanda, funded by the U.S. Government and the Global Fund to | Surgery_Schwartz. chapters, films, grants, research trials) that pres-ent new avenues for academic advancement supporting both colleagues from abroad as well as the home institution. More importantly, Ministries of Health are responding to results of these scholarly works by designing policies that include surgi-cal care in their countrywide health plans.Partnering academic programs from high-income coun-tries with LMICs and/or with NGOs provides opportuni-ties for collaboration183 (Box: Academic Global Surgery 13Global surgery engagementsLEVEL OF INTEGRATIONAssociationAllianceCollaborationPartnership+–Figure 49-33. Training outcomes from NGO/academic partner-ship. (Reproduced with permission from IVUmed and Intermoun-tain Healthcare.)Academic Global Surgery PartnershipsA. Rwanda Human Resources for Health (HRH) ProgramThe Rwanda Human Resources for Health (HRH) program is an ambitious 7-year long program of the Ministry of Health (MOH) of Rwanda, funded by the U.S. Government and the Global Fund to | [
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Surgery_Schwartz_13704 | Surgery_Schwartz | (HRH) ProgramThe Rwanda Human Resources for Health (HRH) program is an ambitious 7-year long program of the Ministry of Health (MOH) of Rwanda, funded by the U.S. Government and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The HRH Program seeks to greatly expand and improve Rwanda’s health care workforce by strengthening national training programs of specialized physicians, nurses, oral health providers, and health managers. The HRH Program is also designed to strengthen the capacity of academic institutions in Rwanda to sustain the training programs initiated and supported by the HRH Program through (a) recruitment and retention of Rwandan faculty, (b) transfer of knowledge and skills to Rwandan faculty, (c) establishment of additional academic partnerships and collaborations between Rwandan academic institutions and U.S. academic institutions. Currently, 22 U.S. academic medical centers and universities are participating in this program, in collaboration with the | Surgery_Schwartz. (HRH) ProgramThe Rwanda Human Resources for Health (HRH) program is an ambitious 7-year long program of the Ministry of Health (MOH) of Rwanda, funded by the U.S. Government and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The HRH Program seeks to greatly expand and improve Rwanda’s health care workforce by strengthening national training programs of specialized physicians, nurses, oral health providers, and health managers. The HRH Program is also designed to strengthen the capacity of academic institutions in Rwanda to sustain the training programs initiated and supported by the HRH Program through (a) recruitment and retention of Rwandan faculty, (b) transfer of knowledge and skills to Rwandan faculty, (c) establishment of additional academic partnerships and collaborations between Rwandan academic institutions and U.S. academic institutions. Currently, 22 U.S. academic medical centers and universities are participating in this program, in collaboration with the | [
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Surgery_Schwartz_13705 | Surgery_Schwartz | between Rwandan academic institutions and U.S. academic institutions. Currently, 22 U.S. academic medical centers and universities are participating in this program, in collaboration with the University of Rwanda—College of Medicine and Health Sciences (UR-CMHS) training faculty. Since the launch of the program in 2012, U.S. institutions have deployed about 100 faculty members per year across these four health-related professions. The recruited U.S. faculty are twinned with UR faculty and senior trainees, paired along common goals and interests, and together they engage in a diversity of activities—including teaching, training, research, clinical care, and care delivery improvement projects.The program is currently in its fifth year (August 2016–July 2017). Focusing our discussion on the surgical disciplines, the annual intake of postgraduate students (residents) has dramatically increased. The anesthesiology residency, whose annual matriculation ranged from zero to three residents, | Surgery_Schwartz. between Rwandan academic institutions and U.S. academic institutions. Currently, 22 U.S. academic medical centers and universities are participating in this program, in collaboration with the University of Rwanda—College of Medicine and Health Sciences (UR-CMHS) training faculty. Since the launch of the program in 2012, U.S. institutions have deployed about 100 faculty members per year across these four health-related professions. The recruited U.S. faculty are twinned with UR faculty and senior trainees, paired along common goals and interests, and together they engage in a diversity of activities—including teaching, training, research, clinical care, and care delivery improvement projects.The program is currently in its fifth year (August 2016–July 2017). Focusing our discussion on the surgical disciplines, the annual intake of postgraduate students (residents) has dramatically increased. The anesthesiology residency, whose annual matriculation ranged from zero to three residents, | [
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Surgery_Schwartz_13706 | Surgery_Schwartz | surgical disciplines, the annual intake of postgraduate students (residents) has dramatically increased. The anesthesiology residency, whose annual matriculation ranged from zero to three residents, now routinely admits 10 new residents yearly. The surgery residency has divided into the four specialties of general surgery, orthopedics, urology, and neurosurgery. Annual matriculation across all for programs now ranges from 15 to 20 compared to 3 to 6, prior to the HRH program’s support of the surgery department. In July 2016, UR graduated eight new general surgeons and one new urologist, the largest output to date. Similar training output is noted across the other disciplines and specialties as well. As a result, Rwanda is now on track to achieve most of its targets for the health workforce. Most graduates are deployed across provincial hospitals to provide specialty level care in a decentralized fashion, while a portion are maintained at the teaching hospitals to be recruited as new | Surgery_Schwartz. surgical disciplines, the annual intake of postgraduate students (residents) has dramatically increased. The anesthesiology residency, whose annual matriculation ranged from zero to three residents, now routinely admits 10 new residents yearly. The surgery residency has divided into the four specialties of general surgery, orthopedics, urology, and neurosurgery. Annual matriculation across all for programs now ranges from 15 to 20 compared to 3 to 6, prior to the HRH program’s support of the surgery department. In July 2016, UR graduated eight new general surgeons and one new urologist, the largest output to date. Similar training output is noted across the other disciplines and specialties as well. As a result, Rwanda is now on track to achieve most of its targets for the health workforce. Most graduates are deployed across provincial hospitals to provide specialty level care in a decentralized fashion, while a portion are maintained at the teaching hospitals to be recruited as new | [
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Surgery_Schwartz_13707 | Surgery_Schwartz | Most graduates are deployed across provincial hospitals to provide specialty level care in a decentralized fashion, while a portion are maintained at the teaching hospitals to be recruited as new faculty. The HRH Program also aims to strengthen the quality of the training programs through competency-based training and pedagogic innovation, improvements in infrastructure and equipment within the schools at the CMHS and the teaching hospitals, and stronger administration of the training programs. As the HRH program comes into its final years, efforts are underway towards faculty professional development program that will both ensure that the UR-CMHS is able to Partnerships). Global surgery engagements exist along a con-tinuum from simple associations, to alliances, collaborations, or formal partnerships (Fig. 49-33). A true partnership usually involves specified and joint rights and responsibilities. The other engagements vary depending on the amount of integra-tion between the | Surgery_Schwartz. Most graduates are deployed across provincial hospitals to provide specialty level care in a decentralized fashion, while a portion are maintained at the teaching hospitals to be recruited as new faculty. The HRH Program also aims to strengthen the quality of the training programs through competency-based training and pedagogic innovation, improvements in infrastructure and equipment within the schools at the CMHS and the teaching hospitals, and stronger administration of the training programs. As the HRH program comes into its final years, efforts are underway towards faculty professional development program that will both ensure that the UR-CMHS is able to Partnerships). Global surgery engagements exist along a con-tinuum from simple associations, to alliances, collaborations, or formal partnerships (Fig. 49-33). A true partnership usually involves specified and joint rights and responsibilities. The other engagements vary depending on the amount of integra-tion between the | [
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Surgery_Schwartz_13708 | Surgery_Schwartz | formal partnerships (Fig. 49-33). A true partnership usually involves specified and joint rights and responsibilities. The other engagements vary depending on the amount of integra-tion between the institutions and organizations. Successful sustainable progress for global surgery can occur within any of the different levels of engagement. Many partnerships begin with a simple association or alliance before growing into a formal partnership.Academic Global Surgery helped progress the founda-tional knowledge in defining the burden of surgical disease, clarifying the cost-effectiveness of surgical care, and estab-lishing baseline values of surgical capacity.184 Further work is necessary to move beyond data collection and to use this foun-dational knowledge to now develop interventional strategies and stimulate sustainable solutions for accessible, affordable, appropriate surgical care for all.185Brunicardi_Ch49_p2077-p2112.indd 210413/02/19 5:54 PM 2105GLOBAL SURGERYCHAPTER | Surgery_Schwartz. formal partnerships (Fig. 49-33). A true partnership usually involves specified and joint rights and responsibilities. The other engagements vary depending on the amount of integra-tion between the institutions and organizations. Successful sustainable progress for global surgery can occur within any of the different levels of engagement. Many partnerships begin with a simple association or alliance before growing into a formal partnership.Academic Global Surgery helped progress the founda-tional knowledge in defining the burden of surgical disease, clarifying the cost-effectiveness of surgical care, and estab-lishing baseline values of surgical capacity.184 Further work is necessary to move beyond data collection and to use this foun-dational knowledge to now develop interventional strategies and stimulate sustainable solutions for accessible, affordable, appropriate surgical care for all.185Brunicardi_Ch49_p2077-p2112.indd 210413/02/19 5:54 PM 2105GLOBAL SURGERYCHAPTER | [
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Surgery_Schwartz_13709 | Surgery_Schwartz | strategies and stimulate sustainable solutions for accessible, affordable, appropriate surgical care for all.185Brunicardi_Ch49_p2077-p2112.indd 210413/02/19 5:54 PM 2105GLOBAL SURGERYCHAPTER 49continue making the aforementioned human resource gains independent of this large foreign aid grant, and that the relationships and collaborations forged between academic institutions may continue to grow and find new avenues for productive work together.186—Robert Riviello, MD, MPH, FACSB. Coordinating Nongovernmental Organizations (NGO) and Academic Organizations: IVUmedNonprofit organizations (NGO) have filled a niche in establishing surgical care in countries where training centers and healthcare systems are historically nonexistent or understaffed. More recently, professional organizations have developed a focus on specific diseases or patient groups and have become a resource for education and training in poor countries.For more than 20 years, the IVUmed NGO has focused on urological | Surgery_Schwartz. strategies and stimulate sustainable solutions for accessible, affordable, appropriate surgical care for all.185Brunicardi_Ch49_p2077-p2112.indd 210413/02/19 5:54 PM 2105GLOBAL SURGERYCHAPTER 49continue making the aforementioned human resource gains independent of this large foreign aid grant, and that the relationships and collaborations forged between academic institutions may continue to grow and find new avenues for productive work together.186—Robert Riviello, MD, MPH, FACSB. Coordinating Nongovernmental Organizations (NGO) and Academic Organizations: IVUmedNonprofit organizations (NGO) have filled a niche in establishing surgical care in countries where training centers and healthcare systems are historically nonexistent or understaffed. More recently, professional organizations have developed a focus on specific diseases or patient groups and have become a resource for education and training in poor countries.For more than 20 years, the IVUmed NGO has focused on urological | [
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Surgery_Schwartz_13710 | Surgery_Schwartz | have developed a focus on specific diseases or patient groups and have become a resource for education and training in poor countries.For more than 20 years, the IVUmed NGO has focused on urological education and hands-on training in Africa, Asia, and Latin America. IVUmed evolved from a need identified by plastic surgeons that had seen many children with hypospadias and other urological anomalies, such as exstrophy, when providing care for children with cleft lip and palate. Adult surgeons were not trained in the delicate reconstruction of pediatric genitourinary anomalies, and pediatric surgeons were not trained in endoscopic or reconstructive urological surgery. The program has expanded to support training in all aspects of urological care, including adult reconstruction, oncology, and endoscopic management of stones and prostatic disease.As a nonprofit organization, IVUmed is a partnership between surgeons, anesthesiologists and nurses, academic medical centers, urological | Surgery_Schwartz. have developed a focus on specific diseases or patient groups and have become a resource for education and training in poor countries.For more than 20 years, the IVUmed NGO has focused on urological education and hands-on training in Africa, Asia, and Latin America. IVUmed evolved from a need identified by plastic surgeons that had seen many children with hypospadias and other urological anomalies, such as exstrophy, when providing care for children with cleft lip and palate. Adult surgeons were not trained in the delicate reconstruction of pediatric genitourinary anomalies, and pediatric surgeons were not trained in endoscopic or reconstructive urological surgery. The program has expanded to support training in all aspects of urological care, including adult reconstruction, oncology, and endoscopic management of stones and prostatic disease.As a nonprofit organization, IVUmed is a partnership between surgeons, anesthesiologists and nurses, academic medical centers, urological | [
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Surgery_Schwartz_13711 | Surgery_Schwartz | and endoscopic management of stones and prostatic disease.As a nonprofit organization, IVUmed is a partnership between surgeons, anesthesiologists and nurses, academic medical centers, urological professional associations, industry, and the public with urologic surgery training in more than 20 countries. It also provides North American trainees scholarships to travel to low-resource countries to learn and to share knowledge gained in their own programs. Many former scholars become mentors for other residents when they complete their training. The sites with the longest collaborations have developed their own educational programs in general urology or subspecialty areas and are now providing advanced training and care locally (see Fig. 49-33).C. Cancer Disparities Consortium in West AfricaNoncommunicable diseases, such as cancer, are a major public health problem in lowand middle-income countries (LMIC). In many LMIC, surgeons, due to the lack of medical oncologists, treat all stages | Surgery_Schwartz. and endoscopic management of stones and prostatic disease.As a nonprofit organization, IVUmed is a partnership between surgeons, anesthesiologists and nurses, academic medical centers, urological professional associations, industry, and the public with urologic surgery training in more than 20 countries. It also provides North American trainees scholarships to travel to low-resource countries to learn and to share knowledge gained in their own programs. Many former scholars become mentors for other residents when they complete their training. The sites with the longest collaborations have developed their own educational programs in general urology or subspecialty areas and are now providing advanced training and care locally (see Fig. 49-33).C. Cancer Disparities Consortium in West AfricaNoncommunicable diseases, such as cancer, are a major public health problem in lowand middle-income countries (LMIC). In many LMIC, surgeons, due to the lack of medical oncologists, treat all stages | [
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Surgery_Schwartz_13712 | Surgery_Schwartz | diseases, such as cancer, are a major public health problem in lowand middle-income countries (LMIC). In many LMIC, surgeons, due to the lack of medical oncologists, treat all stages of noninfectious related cancers, such as breast and colorectal cancer (CRC). In 2011, to address the disparity in outcomes for patients with cancer in West Africa compared to the United States, a research and training collaboration was formed between the Obafemi Awolowo University Teaching Hospital in Nigeria and Memorial Sloan Kettering Cancer Center (MSK) in New York. This relationship has now grown to become a consortium of five Nigerian hospitals and the Global Cancer Disparity Initiative Team at MSK.The consortium began by focusing on important questions regarding CRC: how can early stage patients be identified; what are the demographics of CRC patients in Nigeria; and is the biology of CRC different in Nigeria compared to the USA? These questions are being answered, with the support of two NIH | Surgery_Schwartz. diseases, such as cancer, are a major public health problem in lowand middle-income countries (LMIC). In many LMIC, surgeons, due to the lack of medical oncologists, treat all stages of noninfectious related cancers, such as breast and colorectal cancer (CRC). In 2011, to address the disparity in outcomes for patients with cancer in West Africa compared to the United States, a research and training collaboration was formed between the Obafemi Awolowo University Teaching Hospital in Nigeria and Memorial Sloan Kettering Cancer Center (MSK) in New York. This relationship has now grown to become a consortium of five Nigerian hospitals and the Global Cancer Disparity Initiative Team at MSK.The consortium began by focusing on important questions regarding CRC: how can early stage patients be identified; what are the demographics of CRC patients in Nigeria; and is the biology of CRC different in Nigeria compared to the USA? These questions are being answered, with the support of two NIH | [
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Surgery_Schwartz_13713 | Surgery_Schwartz | identified; what are the demographics of CRC patients in Nigeria; and is the biology of CRC different in Nigeria compared to the USA? These questions are being answered, with the support of two NIH grants, by creating a robust prospective database with a matching biobank. With over 250 patients, the consortium can now describe the metastatic patterns, stages of presentation, and risk factors for CRC in West Africa. Given that over 65% of patients present with stage IV disease, the development of a risk model to identify patients with early stage disease is a priority. This is being accomplished with a 400-patient prospective trial of colonoscopy in patients over 45 years of age with rectal bleeding in three Nigerian cities. Future projects include studying new technologies for CRC and breast cancer screening.—Peter Kingham, MD, FACSEthicsThe ethics involved in working outside one’s own country are complex. While a practitioner’s scope of practice is usually constrained by regulation | Surgery_Schwartz. identified; what are the demographics of CRC patients in Nigeria; and is the biology of CRC different in Nigeria compared to the USA? These questions are being answered, with the support of two NIH grants, by creating a robust prospective database with a matching biobank. With over 250 patients, the consortium can now describe the metastatic patterns, stages of presentation, and risk factors for CRC in West Africa. Given that over 65% of patients present with stage IV disease, the development of a risk model to identify patients with early stage disease is a priority. This is being accomplished with a 400-patient prospective trial of colonoscopy in patients over 45 years of age with rectal bleeding in three Nigerian cities. Future projects include studying new technologies for CRC and breast cancer screening.—Peter Kingham, MD, FACSEthicsThe ethics involved in working outside one’s own country are complex. While a practitioner’s scope of practice is usually constrained by regulation | [
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Surgery_Schwartz_13714 | Surgery_Schwartz | cancer screening.—Peter Kingham, MD, FACSEthicsThe ethics involved in working outside one’s own country are complex. While a practitioner’s scope of practice is usually constrained by regulation in America and Europe, in many countries the limits of what one can do are neither regulated nor enforced. Guidelines for what should be done, where, and under what circumstances are beyond the expertise of some ministries of health. Some problems are so episodic that they are not anticipated, and few guidelines exist. For example, in natural disasters and emergencies, should any willing provider from any country be granted permission to provide care? Should specific disaster-related training be encouraged or required?187,188 In the nonacute setting, should practitioners not licensed or credentialed in their home environments be allowed to perform volunteer surgery in other countries? What entity should oversee the flow of volunteer practitioners? Can a standard set of guidelines meet the | Surgery_Schwartz. cancer screening.—Peter Kingham, MD, FACSEthicsThe ethics involved in working outside one’s own country are complex. While a practitioner’s scope of practice is usually constrained by regulation in America and Europe, in many countries the limits of what one can do are neither regulated nor enforced. Guidelines for what should be done, where, and under what circumstances are beyond the expertise of some ministries of health. Some problems are so episodic that they are not anticipated, and few guidelines exist. For example, in natural disasters and emergencies, should any willing provider from any country be granted permission to provide care? Should specific disaster-related training be encouraged or required?187,188 In the nonacute setting, should practitioners not licensed or credentialed in their home environments be allowed to perform volunteer surgery in other countries? What entity should oversee the flow of volunteer practitioners? Can a standard set of guidelines meet the | [
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Surgery_Schwartz_13715 | Surgery_Schwartz | in their home environments be allowed to perform volunteer surgery in other countries? What entity should oversee the flow of volunteer practitioners? Can a standard set of guidelines meet the needs of most countries? Currently, there is little cross-national agreement between state entities, like ministries of health and independent organizations and individuals. While many countries require at least temporary licensure, some do not. In many cases enforce-ment is inconsistent.With respect to research, the poor historically have not received benefit from research performed on them. In inter-national studies, even local collaborators have been left out of study design and publication.189 As internet communications have improved, these lapses are no longer tolerated.190 Informed consent for surgical procedures, in the appropriate language and respectful of local customs, is becoming the norm. Few hospitals outside academic medical centers have institutional review boards (IRBs) to | Surgery_Schwartz. in their home environments be allowed to perform volunteer surgery in other countries? What entity should oversee the flow of volunteer practitioners? Can a standard set of guidelines meet the needs of most countries? Currently, there is little cross-national agreement between state entities, like ministries of health and independent organizations and individuals. While many countries require at least temporary licensure, some do not. In many cases enforce-ment is inconsistent.With respect to research, the poor historically have not received benefit from research performed on them. In inter-national studies, even local collaborators have been left out of study design and publication.189 As internet communications have improved, these lapses are no longer tolerated.190 Informed consent for surgical procedures, in the appropriate language and respectful of local customs, is becoming the norm. Few hospitals outside academic medical centers have institutional review boards (IRBs) to | [
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Surgery_Schwartz_13716 | Surgery_Schwartz | for surgical procedures, in the appropriate language and respectful of local customs, is becoming the norm. Few hospitals outside academic medical centers have institutional review boards (IRBs) to oversee the implementation and review of clinical research. In recent years, peer reviewed journals have become more mindful of attribution of credit, and authors are strongly encouraged to design and report studies with local input at all levels.With regard to transplantation, many countries have laws against cadaveric transplants because of the very real concern for illegal marketing of organs. Even living-donor Brunicardi_Ch49_p2077-p2112.indd 210513/02/19 5:54 PM 2106SPECIFIC CONSIDERATIONSPART IItransplantation has seen effects of coercion in some regions and for some populations such as prisoners. Nevertheless, the need and popular desire for transplantation is accelerating acquisition of skills and technology to make transplantation available worldwide.191Finally, what is | Surgery_Schwartz. for surgical procedures, in the appropriate language and respectful of local customs, is becoming the norm. Few hospitals outside academic medical centers have institutional review boards (IRBs) to oversee the implementation and review of clinical research. In recent years, peer reviewed journals have become more mindful of attribution of credit, and authors are strongly encouraged to design and report studies with local input at all levels.With regard to transplantation, many countries have laws against cadaveric transplants because of the very real concern for illegal marketing of organs. Even living-donor Brunicardi_Ch49_p2077-p2112.indd 210513/02/19 5:54 PM 2106SPECIFIC CONSIDERATIONSPART IItransplantation has seen effects of coercion in some regions and for some populations such as prisoners. Nevertheless, the need and popular desire for transplantation is accelerating acquisition of skills and technology to make transplantation available worldwide.191Finally, what is | [
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Surgery_Schwartz_13717 | Surgery_Schwartz | such as prisoners. Nevertheless, the need and popular desire for transplantation is accelerating acquisition of skills and technology to make transplantation available worldwide.191Finally, what is considered ethical in one country or com-munity might be considered highly unethical in another. Con-sent for surgery may in one setting rest with the patient, but in another, with the community or family. Values about privacy vary markedly from region to region. Health information in many cultures is considered to be a community concern, not the personal property of an individual patient.Innovation in Global SurgeryThe pressing need for surgical care at all levels and the shortage of fully trained surgeons, anesthesiologists, and support personnel as well as equipment and supplies means that opportunities abound for innovation. Innovations in education, including simulation, can shorten the time necessary for learn-ing technical skills. Gaming technology can teach algorithms for | Surgery_Schwartz. such as prisoners. Nevertheless, the need and popular desire for transplantation is accelerating acquisition of skills and technology to make transplantation available worldwide.191Finally, what is considered ethical in one country or com-munity might be considered highly unethical in another. Con-sent for surgery may in one setting rest with the patient, but in another, with the community or family. Values about privacy vary markedly from region to region. Health information in many cultures is considered to be a community concern, not the personal property of an individual patient.Innovation in Global SurgeryThe pressing need for surgical care at all levels and the shortage of fully trained surgeons, anesthesiologists, and support personnel as well as equipment and supplies means that opportunities abound for innovation. Innovations in education, including simulation, can shorten the time necessary for learn-ing technical skills. Gaming technology can teach algorithms for | [
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Surgery_Schwartz_13718 | Surgery_Schwartz | that opportunities abound for innovation. Innovations in education, including simulation, can shorten the time necessary for learn-ing technical skills. Gaming technology can teach algorithms for interpretation of X-rays and ultrasounds. Telemedicine/tele-health is transforming education through combinations of clini-cal case-based learning and massively open online courses (MOOC) (Box: Telemedicine). The potential for education innovation in surgery beyond the apprenticeship system cham-pioned by Halsted in 1904 is vast.14Sophisticatedtechnology thatsimplifiesLow-cost,innovativebusiness modelsEconomicallycoherent valuenetworkRegulations and standards thatfacilitatechangeFigure 49-34. Elements of disruptive innovation. (Reproduced with permission from Intermountain Healthcare.)Innovation that radically changes the way we do things and that changes a paradigm of a service or system is called “disruptive”; it abruptly changes an older and more expensive system in favor of a less | Surgery_Schwartz. that opportunities abound for innovation. Innovations in education, including simulation, can shorten the time necessary for learn-ing technical skills. Gaming technology can teach algorithms for interpretation of X-rays and ultrasounds. Telemedicine/tele-health is transforming education through combinations of clini-cal case-based learning and massively open online courses (MOOC) (Box: Telemedicine). The potential for education innovation in surgery beyond the apprenticeship system cham-pioned by Halsted in 1904 is vast.14Sophisticatedtechnology thatsimplifiesLow-cost,innovativebusiness modelsEconomicallycoherent valuenetworkRegulations and standards thatfacilitatechangeFigure 49-34. Elements of disruptive innovation. (Reproduced with permission from Intermountain Healthcare.)Innovation that radically changes the way we do things and that changes a paradigm of a service or system is called “disruptive”; it abruptly changes an older and more expensive system in favor of a less | [
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Surgery_Schwartz_13719 | Surgery_Schwartz | that radically changes the way we do things and that changes a paradigm of a service or system is called “disruptive”; it abruptly changes an older and more expensive system in favor of a less expensive, more widely available technology or process. The ability for disruptive innovations to transform products and services into affordable realities requires three main factors: a sophisticated technology that simplifies, a low-cost business model, and an economically coherent value network (Fig. 49-34).195Regulations and standards that vary between countries and locales can facilitate or impede disruptive change. While disrup-tions often are not qualitatively superior to the status quo, they make the process both less expensive and more accessible, and through multiple iterations, ultimately improve quality as they cycle through the transformative process.Decentralizing education, laboratory testing, and medical records have been made possible through free and open-source software, apps, | Surgery_Schwartz. that radically changes the way we do things and that changes a paradigm of a service or system is called “disruptive”; it abruptly changes an older and more expensive system in favor of a less expensive, more widely available technology or process. The ability for disruptive innovations to transform products and services into affordable realities requires three main factors: a sophisticated technology that simplifies, a low-cost business model, and an economically coherent value network (Fig. 49-34).195Regulations and standards that vary between countries and locales can facilitate or impede disruptive change. While disrup-tions often are not qualitatively superior to the status quo, they make the process both less expensive and more accessible, and through multiple iterations, ultimately improve quality as they cycle through the transformative process.Decentralizing education, laboratory testing, and medical records have been made possible through free and open-source software, apps, | [
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Surgery_Schwartz_13720 | Surgery_Schwartz | improve quality as they cycle through the transformative process.Decentralizing education, laboratory testing, and medical records have been made possible through free and open-source software, apps, and devices such as smart phones, tablets, and laptop computers. Monitoring and imaging devices and lapa-roscopic instruments designed for low resource environments have the potential to not only improve accessibility in poor countries but also to radically reduce surgical costs in wealthy ones.196THE FUTURE FOR GLOBAL SURGERYSurgeons of the future will need to educate themselves in areas that have not historically been taught in surgical curricula. Beyond the technical aspects of surgical practice, there is a complex ecosystem that supports surgical care. Surgeons must become more aware of the complexities of cost in order to be able to shape the environment in which they work. They must understand better what patients are seeking from the surgical experience, rather than focusing | Surgery_Schwartz. improve quality as they cycle through the transformative process.Decentralizing education, laboratory testing, and medical records have been made possible through free and open-source software, apps, and devices such as smart phones, tablets, and laptop computers. Monitoring and imaging devices and lapa-roscopic instruments designed for low resource environments have the potential to not only improve accessibility in poor countries but also to radically reduce surgical costs in wealthy ones.196THE FUTURE FOR GLOBAL SURGERYSurgeons of the future will need to educate themselves in areas that have not historically been taught in surgical curricula. Beyond the technical aspects of surgical practice, there is a complex ecosystem that supports surgical care. Surgeons must become more aware of the complexities of cost in order to be able to shape the environment in which they work. They must understand better what patients are seeking from the surgical experience, rather than focusing | [
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Surgery_Schwartz_13721 | Surgery_Schwartz | of the complexities of cost in order to be able to shape the environment in which they work. They must understand better what patients are seeking from the surgical experience, rather than focusing primarily on a narrow view of what surgery might have to offer. Surgeons must engage in policy development and advocate for affordable and accessible surgical care without sacrificing quality. Thoughtful technology design can focus on improving quality and on decreasing cost, both in poor and wealthy countries. Building surgical capac-ity through a health systems-focused approach, with robust data collection, and establishment of global surgery centers of Telementoring in Global SurgeryOne excellent example of successful telementoring in surgery is a program started by Allan Okrainec, MD, a minimally invasive surgeon at the University of Toronto, and Georges Azzie, MD, a pediatric surgeon at Toronto’s Hospital for Sick Children. In the mid-2000s, the two imagined utilizing laparoscopic box | Surgery_Schwartz. of the complexities of cost in order to be able to shape the environment in which they work. They must understand better what patients are seeking from the surgical experience, rather than focusing primarily on a narrow view of what surgery might have to offer. Surgeons must engage in policy development and advocate for affordable and accessible surgical care without sacrificing quality. Thoughtful technology design can focus on improving quality and on decreasing cost, both in poor and wealthy countries. Building surgical capac-ity through a health systems-focused approach, with robust data collection, and establishment of global surgery centers of Telementoring in Global SurgeryOne excellent example of successful telementoring in surgery is a program started by Allan Okrainec, MD, a minimally invasive surgeon at the University of Toronto, and Georges Azzie, MD, a pediatric surgeon at Toronto’s Hospital for Sick Children. In the mid-2000s, the two imagined utilizing laparoscopic box | [
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Surgery_Schwartz_13722 | Surgery_Schwartz | invasive surgeon at the University of Toronto, and Georges Azzie, MD, a pediatric surgeon at Toronto’s Hospital for Sick Children. In the mid-2000s, the two imagined utilizing laparoscopic box trainers and videoconferencing technology via Skype to teach minimally invasive techniques to surgeons in LMICs.192 As part of the “Go Global” Initiative of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dr. Okrainec’s team traveled to Botswana in 2007 to teach a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in person. Although only two of twenty surgeons achieved certification, average posttest scores showed promising improvement.Realizing that continued mentorship promotes success, Dr. Okrainec’s team reconfigured their teaching model to include telesimulation. In 2009, they carried out an 8-week course in FLS, with weekly meetings via videoconference and real-time simulation demonstration and feedback between Botswana and Toronto. This time, 100% of | Surgery_Schwartz. invasive surgeon at the University of Toronto, and Georges Azzie, MD, a pediatric surgeon at Toronto’s Hospital for Sick Children. In the mid-2000s, the two imagined utilizing laparoscopic box trainers and videoconferencing technology via Skype to teach minimally invasive techniques to surgeons in LMICs.192 As part of the “Go Global” Initiative of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Dr. Okrainec’s team traveled to Botswana in 2007 to teach a 3-day Fundamentals of Laparoscopic Surgery (FLS) course in person. Although only two of twenty surgeons achieved certification, average posttest scores showed promising improvement.Realizing that continued mentorship promotes success, Dr. Okrainec’s team reconfigured their teaching model to include telesimulation. In 2009, they carried out an 8-week course in FLS, with weekly meetings via videoconference and real-time simulation demonstration and feedback between Botswana and Toronto. This time, 100% of | [
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Surgery_Schwartz_13723 | Surgery_Schwartz | In 2009, they carried out an 8-week course in FLS, with weekly meetings via videoconference and real-time simulation demonstration and feedback between Botswana and Toronto. This time, 100% of participants in the tele-simulation group attained certification.193 Subsequently, the team expanded its program to Colombia, with similar success in skill acquisition.194 Since 2009, the program has expanded to 15 countries, with satellite telesimulation sites in Colombia and Ukraine. They have trained more than 300 individuals in FLS skills around the world.Brunicardi_Ch49_p2077-p2112.indd 210613/02/19 5:54 PM 2107GLOBAL SURGERYCHAPTER 49excellence will stimulate improvements in the provision of sur-gical and anesthesia services.197 Further integration of surgical care into national health plans of governments should encour-age increased investments and political will necessary to create capacity, leading to timely, quality surgical care to all without risk of financial ruin.16,91 Our | Surgery_Schwartz. In 2009, they carried out an 8-week course in FLS, with weekly meetings via videoconference and real-time simulation demonstration and feedback between Botswana and Toronto. This time, 100% of participants in the tele-simulation group attained certification.193 Subsequently, the team expanded its program to Colombia, with similar success in skill acquisition.194 Since 2009, the program has expanded to 15 countries, with satellite telesimulation sites in Colombia and Ukraine. They have trained more than 300 individuals in FLS skills around the world.Brunicardi_Ch49_p2077-p2112.indd 210613/02/19 5:54 PM 2107GLOBAL SURGERYCHAPTER 49excellence will stimulate improvements in the provision of sur-gical and anesthesia services.197 Further integration of surgical care into national health plans of governments should encour-age increased investments and political will necessary to create capacity, leading to timely, quality surgical care to all without risk of financial ruin.16,91 Our | [
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Surgery_Schwartz_13724 | Surgery_Schwartz | plans of governments should encour-age increased investments and political will necessary to create capacity, leading to timely, quality surgical care to all without risk of financial ruin.16,91 Our colleagues in public health and the World Bank, Paul Farmer and Jim Kim, have challenged us: “We need our surgical colleagues to speak fluently about rebuilding infrastructure, training, personnel, and delivering high-quality care to the very poorest.”106REFERENCESEntries highlighted in bright blue are key references. 1. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspec-tive. Lancet Glob Health. 2015;3(suppl 2):S8-S9. 2. Weiser TG, Regenbogen SE, Thompson KD, et al. An esti-mation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139-144. 3. Chang L, Lacy BE, Spiegel BM. Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J | Surgery_Schwartz. plans of governments should encour-age increased investments and political will necessary to create capacity, leading to timely, quality surgical care to all without risk of financial ruin.16,91 Our colleagues in public health and the World Bank, Paul Farmer and Jim Kim, have challenged us: “We need our surgical colleagues to speak fluently about rebuilding infrastructure, training, personnel, and delivering high-quality care to the very poorest.”106REFERENCESEntries highlighted in bright blue are key references. 1. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspec-tive. Lancet Glob Health. 2015;3(suppl 2):S8-S9. 2. Weiser TG, Regenbogen SE, Thompson KD, et al. An esti-mation of the global volume of surgery: a modelling strategy based on available data. Lancet. 2008;372(9633):139-144. 3. Chang L, Lacy BE, Spiegel BM. Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J | [
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Surgery_Schwartz_13725 | Surgery_Schwartz | strategy based on available data. Lancet. 2008;372(9633):139-144. 3. Chang L, Lacy BE, Spiegel BM. Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J Surg. 2011;35(2):272-279. 4. Contini S, Taqdeer A, Cherian M, et al. Emergency and essen-tial surgical services in Afghanistan: still a missing challenge. World J Surg. 2010;34(3):473-479. 5. Choo S, Perry H, Hesse AA, et al. Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hos-pitals using a WHO assessment tool. Trop Med Int Health. 2010;15(9):1109-1115. 6. Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anes-thesia in 8 lowand middle-income countries. Arch Surg. 2010;145(2):154-159. 7. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery. Disease Control Priori-ties. 3rd ed. Vol 1. Washington, DC: World Bank; 2015. doi: | Surgery_Schwartz. strategy based on available data. Lancet. 2008;372(9633):139-144. 3. Chang L, Lacy BE, Spiegel BM. Quantifying surgical and anesthetic availability at primary health facilities in Mongolia. World J Surg. 2011;35(2):272-279. 4. Contini S, Taqdeer A, Cherian M, et al. Emergency and essen-tial surgical services in Afghanistan: still a missing challenge. World J Surg. 2010;34(3):473-479. 5. Choo S, Perry H, Hesse AA, et al. Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hos-pitals using a WHO assessment tool. Trop Med Int Health. 2010;15(9):1109-1115. 6. Kushner AL, Cherian MN, Noel L, Spiegel DA, Groth S, Etienne C. Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anes-thesia in 8 lowand middle-income countries. Arch Surg. 2010;145(2):154-159. 7. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery. Disease Control Priori-ties. 3rd ed. Vol 1. Washington, DC: World Bank; 2015. doi: | [
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Surgery_Schwartz_13729 | Surgery_Schwartz | 2018. 20. Lancet Commissioners. The Lancet Commission on global surgery, 2015. Available at: http://www.lancetglobalsurgery .org/lancet-commissioners. Accessed August 22, 2018. 21. 68th World Health Assembly. Emergency and Essential Surgi-cal Care, World Health Organization. Available at: http://who .int/surgery/wha-eb/en/ 22. Dare AJ, Grimes CE, Gillies R, et al. Global Surgery: defining an emerging global health field. Lancet. 2014;384:2245-2247. 23. deVries CR, Rosenberg JS. Global surgical ecosys-tems: a need for systems strengthening. Ann Glob Health. 2016;82(4):605-613. 24. Chu K, Rosseel P, Gielis P, Ford N. Surgical task shifting in Sub-Saharan Africa. PLoS Med. 2009;6:e1000078. 25. Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: role of surgeons and other providers. Adv Surg. 2008;42:63-85. 26. Crisp N, Chen L. Global supply of health professionals. New Engl J Med. 2014;370:950-957. 27. Mkandawire N, Ngulube C, Lavy C. | Surgery_Schwartz. 2018. 20. Lancet Commissioners. The Lancet Commission on global surgery, 2015. Available at: http://www.lancetglobalsurgery .org/lancet-commissioners. Accessed August 22, 2018. 21. 68th World Health Assembly. Emergency and Essential Surgi-cal Care, World Health Organization. Available at: http://who .int/surgery/wha-eb/en/ 22. Dare AJ, Grimes CE, Gillies R, et al. Global Surgery: defining an emerging global health field. Lancet. 2014;384:2245-2247. 23. deVries CR, Rosenberg JS. Global surgical ecosys-tems: a need for systems strengthening. Ann Glob Health. 2016;82(4):605-613. 24. Chu K, Rosseel P, Gielis P, Ford N. Surgical task shifting in Sub-Saharan Africa. PLoS Med. 2009;6:e1000078. 25. Sheldon GF, Ricketts TC, Charles A, King J, Fraher EP, Meyer A. The global health workforce shortage: role of surgeons and other providers. Adv Surg. 2008;42:63-85. 26. Crisp N, Chen L. Global supply of health professionals. New Engl J Med. 2014;370:950-957. 27. Mkandawire N, Ngulube C, Lavy C. | [
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Surgery_Schwartz_13731 | Surgery_Schwartz | White TW, Stevens MH, Van Boerum DH. A role in trauma care for advanced practice clinicians. JAAPA. 2009;22(6):33-36, 41. 31. Ozgediz D, Kijjambu S, Galukande M, et al. Africa’s neglected surgical workforce crisis. Lancet. 2008;371:627-628. 32. Rodriguez MI, Gordon-Maclean C. The safety, efficacy and acceptability of task sharing tubal sterilization to midlevel providers: a systematic review. Contraception. 2014;89(6):504-511. 33. Mullan, F. The metrics of the physician brain drain. N Engl J Med. 2005;353(17):1810-1818. 34. Humphries N, McAleese S, Matthews A, Brugha R. “Emigra-tion is a matter of self-preservation. The working conditions...are killing us slowly”: qualitative insights into health professional emigration from Ireland. Hum Resour Health. 2015;13:35. 35. Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health. | Surgery_Schwartz. White TW, Stevens MH, Van Boerum DH. A role in trauma care for advanced practice clinicians. JAAPA. 2009;22(6):33-36, 41. 31. Ozgediz D, Kijjambu S, Galukande M, et al. Africa’s neglected surgical workforce crisis. Lancet. 2008;371:627-628. 32. Rodriguez MI, Gordon-Maclean C. The safety, efficacy and acceptability of task sharing tubal sterilization to midlevel providers: a systematic review. Contraception. 2014;89(6):504-511. 33. Mullan, F. The metrics of the physician brain drain. N Engl J Med. 2005;353(17):1810-1818. 34. Humphries N, McAleese S, Matthews A, Brugha R. “Emigra-tion is a matter of self-preservation. The working conditions...are killing us slowly”: qualitative insights into health professional emigration from Ireland. Hum Resour Health. 2015;13:35. 35. Hagopian A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health. | [
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Surgery_Schwartz_13732 | Surgery_Schwartz | A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health. 2004;2(1):17. 36. Tankwanchi AB, Vermund SH, Perkins DD. Moni-toring Sub-Saharan African physician migration and recruitment post-adoption of the WHO code of practice: tem-poral and geographic patterns in the United States. PLoS One. 2015;10(4):e0124734.Brunicardi_Ch49_p2077-p2112.indd 210713/02/19 5:54 PM 2108SPECIFIC CONSIDERATIONSPART II 37. Hagander LE, Hughes CD, Nash K, et al. Surgeon migra-tion between developing countries and the United States: train, retain, and gain from brain drain. World J Surg. 2013;37(1):14-23. 38. Mills EJ, Schabas WA, Volmink J, et al. Should active recruit-ment of health workers from Sub-Saharan Africa be viewed as a crime? Lancet. 2008;371:685-688. 39. McCoy D, Bennett S, Witter S, et al. Salaries and incomes of health workers in sub-Saharan Africa. Lancet. | Surgery_Schwartz. A, Thompson MJ, Fordyce M, Johnson KE, Hart LG. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Hum Resour Health. 2004;2(1):17. 36. Tankwanchi AB, Vermund SH, Perkins DD. Moni-toring Sub-Saharan African physician migration and recruitment post-adoption of the WHO code of practice: tem-poral and geographic patterns in the United States. PLoS One. 2015;10(4):e0124734.Brunicardi_Ch49_p2077-p2112.indd 210713/02/19 5:54 PM 2108SPECIFIC CONSIDERATIONSPART II 37. Hagander LE, Hughes CD, Nash K, et al. Surgeon migra-tion between developing countries and the United States: train, retain, and gain from brain drain. World J Surg. 2013;37(1):14-23. 38. Mills EJ, Schabas WA, Volmink J, et al. Should active recruit-ment of health workers from Sub-Saharan Africa be viewed as a crime? Lancet. 2008;371:685-688. 39. McCoy D, Bennett S, Witter S, et al. Salaries and incomes of health workers in sub-Saharan Africa. Lancet. | [
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Surgery_Schwartz_13736 | Surgery_Schwartz | prevalence of surgically treatable conditions and avoidable deaths in 48 countries. Lancet. 2015;385(suppl 2):S1. 51. Duda RB, Hill AG. Surgery in developing countries: should surgery have a role in population-based health care? Am Coll Surg Bull. 2007;92(5):12-18, 35. 52. Farmer P, Frenk J, Knaul FM, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet. 2010;376(9747):1186-1193. 53. The Global Burden of Disease Cancer Collaboration. The global burden of cancer 2013. JAMA Oncol. 2015;1:505-527. 54. Mody GN, Nduaguba A, Ntirenganya F, Riviello R. Char-acteristics and presentation of patients with breast cancer in Rwanda. Am J Surg. 2013;205:409-413. 55. Gelband H, Jha P, Sankaranarayanan R, Horton S, eds. Cancer: Disease Control Priorities. 3rd ed. Vol 3. Washington, DC: World Bank; 2015. 56. Hoekstra HJ, Wobbes T, Heineman E, et al. Fighting global disparities in cancer care: a surgical oncology view. Ann Surg Oncol. | Surgery_Schwartz. prevalence of surgically treatable conditions and avoidable deaths in 48 countries. Lancet. 2015;385(suppl 2):S1. 51. Duda RB, Hill AG. Surgery in developing countries: should surgery have a role in population-based health care? Am Coll Surg Bull. 2007;92(5):12-18, 35. 52. Farmer P, Frenk J, Knaul FM, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet. 2010;376(9747):1186-1193. 53. The Global Burden of Disease Cancer Collaboration. The global burden of cancer 2013. JAMA Oncol. 2015;1:505-527. 54. Mody GN, Nduaguba A, Ntirenganya F, Riviello R. Char-acteristics and presentation of patients with breast cancer in Rwanda. Am J Surg. 2013;205:409-413. 55. Gelband H, Jha P, Sankaranarayanan R, Horton S, eds. Cancer: Disease Control Priorities. 3rd ed. Vol 3. Washington, DC: World Bank; 2015. 56. Hoekstra HJ, Wobbes T, Heineman E, et al. Fighting global disparities in cancer care: a surgical oncology view. Ann Surg Oncol. | [
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Surgery_Schwartz_13744 | Surgery_Schwartz | Seventieth session, 25 September 2015. Available at: http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. Accessed August 22, 2018. 89. Kumar S, Kumar N, Vivekadhish S. Millennium development goals (MDGS) to sustainable development goals (SDGS): addressing unfinished agenda and strengthening sustainable development and partnership. Indian J Community Med. 2016;41:1-4. 90. Alma Ata Declaration. October 31, 2012. Available at: http://en.wikipedia.org/wiki/Alma_Ata_Declaration. Accessed 2018. 91. Price R, Makasa E, Hollands M. World Health Assem-bly Resolution WHA68.15: strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage—addressing the public health gaps arising from lack of safe and accessible surgical and anesthetic services. World J Surg. 2015;39:2115-2125. 92. World Health Organization. Primary Health Care: Now More than Ever. Available at: http://www.who.int/whr/2008/whr08_en.pdf. Accessed August 22, | Surgery_Schwartz. Seventieth session, 25 September 2015. Available at: http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. Accessed August 22, 2018. 89. Kumar S, Kumar N, Vivekadhish S. Millennium development goals (MDGS) to sustainable development goals (SDGS): addressing unfinished agenda and strengthening sustainable development and partnership. Indian J Community Med. 2016;41:1-4. 90. Alma Ata Declaration. October 31, 2012. Available at: http://en.wikipedia.org/wiki/Alma_Ata_Declaration. Accessed 2018. 91. Price R, Makasa E, Hollands M. World Health Assem-bly Resolution WHA68.15: strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage—addressing the public health gaps arising from lack of safe and accessible surgical and anesthetic services. World J Surg. 2015;39:2115-2125. 92. World Health Organization. Primary Health Care: Now More than Ever. Available at: http://www.who.int/whr/2008/whr08_en.pdf. Accessed August 22, | [
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Surgery_Schwartz_13748 | Surgery_Schwartz | intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLOS Med. 2005;3(5):e226. 105. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000;14:2361-2370. 106. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32(4):533-536. 107. Learmonth J. The Contributions of Surgery to Preven-tive Medicine. London: Oxford University Press, Geoffrey Cumberlege, Publisher to the University; 1951:55. 108. Brigham and Women’s Hospital. Center for Surgery and Pub-lic Health. Available at: http://www.brighamandwomens.org/research/labs/CenterforSurgeryandPublicHealth/default.aspx. Accessed August 22, 2018. 109. UC San Diego School of Medicine, Department of Surgery. Available at: https://medschool.ucsd.edu/som/surgery/educa-tion/Pages/Global-Surgery.aspx 110. Riviello R, Meara JG, Rogers SO. Commentary: cancer care and | Surgery_Schwartz. intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLOS Med. 2005;3(5):e226. 105. Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000;14:2361-2370. 106. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. 2008;32(4):533-536. 107. Learmonth J. The Contributions of Surgery to Preven-tive Medicine. London: Oxford University Press, Geoffrey Cumberlege, Publisher to the University; 1951:55. 108. Brigham and Women’s Hospital. Center for Surgery and Pub-lic Health. Available at: http://www.brighamandwomens.org/research/labs/CenterforSurgeryandPublicHealth/default.aspx. Accessed August 22, 2018. 109. UC San Diego School of Medicine, Department of Surgery. Available at: https://medschool.ucsd.edu/som/surgery/educa-tion/Pages/Global-Surgery.aspx 110. Riviello R, Meara JG, Rogers SO. Commentary: cancer care and | [
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Surgery_Schwartz_13751 | Surgery_Schwartz | HT, Joshipura M, Chadunchachai W, et al. Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study. World J Surg. 2012;36(8):1978-1992. 119. Gosselin R, Charles A, Joshipura M, et al. Surgery and Trauma Care. Disease Control Priorities. 3rd ed. Vol 1. New York: World Bank; 2015. 120. Mock C, Joshipura M, Arreola-Risa C, Quansah R. An esti-mate of the number of lives that could be saved through improvements in trauma care globally. World J Surg. 2012;36(5):959-963. 121. Liberman M, Mulder D, Lavoie A, et al. Implementation of a trauma care system: evolution through evaluation. J Trauma. 2004;56:1330-1335. 122. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066-1074. 123. World Health Organization. Maternal mortality fact sheet. 2016 Available at: http://www.who.int/mediacentre/factsheets/fs348/en/index.html. Accessed August 22, | Surgery_Schwartz. HT, Joshipura M, Chadunchachai W, et al. Trauma quality improvement in low and middle income countries of the Asia-Pacific region: a mixed methods study. World J Surg. 2012;36(8):1978-1992. 119. Gosselin R, Charles A, Joshipura M, et al. Surgery and Trauma Care. Disease Control Priorities. 3rd ed. Vol 1. New York: World Bank; 2015. 120. Mock C, Joshipura M, Arreola-Risa C, Quansah R. An esti-mate of the number of lives that could be saved through improvements in trauma care globally. World J Surg. 2012;36(5):959-963. 121. Liberman M, Mulder D, Lavoie A, et al. Implementation of a trauma care system: evolution through evaluation. J Trauma. 2004;56:1330-1335. 122. Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: a systematic review. Lancet. 2006;367(9516):1066-1074. 123. World Health Organization. Maternal mortality fact sheet. 2016 Available at: http://www.who.int/mediacentre/factsheets/fs348/en/index.html. Accessed August 22, | [
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Surgery_Schwartz_13754 | Surgery_Schwartz | icb.tabgroup132925. Accessed August 22, 2018. 135. Ozgediz D, Riviello R. The “other” neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med. 2008;5(6):e121. 136. Shillcutt SD, Clarke MG, Kingsnorth AN. Cost-effectiveness of groin hernia surgery in the Western Region of Ghana. Arch Surg. 2010;145(10):954-961. 137. Gosselin RA, Heitto M. Cost-effectiveness of a district trauma hospital in Battambang, Cambodia. World J Surg. 2008;32(11):2450-2453. 138. Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribu-tion of different services? World J Surg. 2006;30(4):505-511. 139. McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet. 2003;81(1):83-92. 140. Alkire BC, Vincent JR, Burns CT, Metzler IS, Farmer PE, Meara JG. Obstructed labor and caesarean delivery: the cost and benefit of surgical | Surgery_Schwartz. icb.tabgroup132925. Accessed August 22, 2018. 135. Ozgediz D, Riviello R. The “other” neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med. 2008;5(6):e121. 136. Shillcutt SD, Clarke MG, Kingsnorth AN. Cost-effectiveness of groin hernia surgery in the Western Region of Ghana. Arch Surg. 2010;145(10):954-961. 137. Gosselin RA, Heitto M. Cost-effectiveness of a district trauma hospital in Battambang, Cambodia. World J Surg. 2008;32(11):2450-2453. 138. Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribu-tion of different services? World J Surg. 2006;30(4):505-511. 139. McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. Int J Gynaecol Obstet. 2003;81(1):83-92. 140. Alkire BC, Vincent JR, Burns CT, Metzler IS, Farmer PE, Meara JG. Obstructed labor and caesarean delivery: the cost and benefit of surgical | [
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Surgery_Schwartz_13755 | Surgery_Schwartz | care. Int J Gynaecol Obstet. 2003;81(1):83-92. 140. Alkire BC, Vincent JR, Burns CT, Metzler IS, Farmer PE, Meara JG. Obstructed labor and caesarean delivery: the cost and benefit of surgical intervention. PLoS One. 2012;7(4):e34595. 141. Murray CJ. Quantifying the burden of disease: the techni-cal basis for disability-adjusted life years. Bull World Health Organ. 1994;72:429-445. 142. Shillcutt SD, Sanders DL, Teresa Butrón-Vila M, Kingsnorth AN. Cost-effectiveness of inguinal hernia surgery in north-western ecuador. World J Surg. 2013;37(1):32-41. 143. Tongaonkar RR, et al. Preliminary multicentric trial of cheap indigenous mosquito-net cloth for tension-free hernia repair. Indian J Surg. 2003;65(1):89-95. 144. Alkire BC, Shrime MG, Dare AJ, et al. The global economic consequences of selected surgical diseases: a modelling study. Lancet Glob Health. 2015;3(suppl 2):S21-S27. 145. United Nations Population Fund (UNFPA); Providing emer-gency obstetric and newborn care to all in need. | Surgery_Schwartz. care. Int J Gynaecol Obstet. 2003;81(1):83-92. 140. Alkire BC, Vincent JR, Burns CT, Metzler IS, Farmer PE, Meara JG. Obstructed labor and caesarean delivery: the cost and benefit of surgical intervention. PLoS One. 2012;7(4):e34595. 141. Murray CJ. Quantifying the burden of disease: the techni-cal basis for disability-adjusted life years. Bull World Health Organ. 1994;72:429-445. 142. Shillcutt SD, Sanders DL, Teresa Butrón-Vila M, Kingsnorth AN. Cost-effectiveness of inguinal hernia surgery in north-western ecuador. World J Surg. 2013;37(1):32-41. 143. Tongaonkar RR, et al. Preliminary multicentric trial of cheap indigenous mosquito-net cloth for tension-free hernia repair. Indian J Surg. 2003;65(1):89-95. 144. Alkire BC, Shrime MG, Dare AJ, et al. The global economic consequences of selected surgical diseases: a modelling study. Lancet Glob Health. 2015;3(suppl 2):S21-S27. 145. United Nations Population Fund (UNFPA); Providing emer-gency obstetric and newborn care to all in need. | [
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Surgery_Schwartz_13758 | Surgery_Schwartz | limited setting: the Mongolian model of the expansion of sustainable laparoscopic cholecystectomy. Surgery. 2016;160(2):509-517. 155. Manning RG, Azziz AQ. Should laparoscopic cholecystec-tomy be practiced in the developing world? The experience of the first training program in Afghanistan. Ann Surg. 2009; 249(5):794-798. 156. Contini S, Taqdeer A, Gosselin RA. Should laparoscopic cho-lecystectomy be practiced in the developing World? The expe-rience of the first training program in Afghanistan. Ann Surg. 2010;251(3):574; author reply 575. 157. Alfa-Wali M, Antoniou A. Should laparoscopic cholecys-tectomy be practiced in the developing world? Ann Surg. 2010;251(2):387; author reply 387-388. 158. Castadot RG, Magarick RH, Sheppard L, Burkman RT. A review of ten years’ experience with surgical equipment in international health programs. Int J Gynaecol Obstet. 1986;24(1):53-60.Brunicardi_Ch49_p2077-p2112.indd 211013/02/19 5:54 PM 2111GLOBAL SURGERYCHAPTER 49 159. Udwadia TE. | Surgery_Schwartz. limited setting: the Mongolian model of the expansion of sustainable laparoscopic cholecystectomy. Surgery. 2016;160(2):509-517. 155. Manning RG, Azziz AQ. Should laparoscopic cholecystec-tomy be practiced in the developing world? The experience of the first training program in Afghanistan. Ann Surg. 2009; 249(5):794-798. 156. Contini S, Taqdeer A, Gosselin RA. Should laparoscopic cho-lecystectomy be practiced in the developing World? The expe-rience of the first training program in Afghanistan. Ann Surg. 2010;251(3):574; author reply 575. 157. Alfa-Wali M, Antoniou A. Should laparoscopic cholecys-tectomy be practiced in the developing world? Ann Surg. 2010;251(2):387; author reply 387-388. 158. Castadot RG, Magarick RH, Sheppard L, Burkman RT. A review of ten years’ experience with surgical equipment in international health programs. Int J Gynaecol Obstet. 1986;24(1):53-60.Brunicardi_Ch49_p2077-p2112.indd 211013/02/19 5:54 PM 2111GLOBAL SURGERYCHAPTER 49 159. Udwadia TE. | [
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Surgery_Schwartz_13759 | Surgery_Schwartz | surgical equipment in international health programs. Int J Gynaecol Obstet. 1986;24(1):53-60.Brunicardi_Ch49_p2077-p2112.indd 211013/02/19 5:54 PM 2111GLOBAL SURGERYCHAPTER 49 159. Udwadia TE. Navigating laparoscopic surgery into the next decade in developing countries—a personal perspec-tive. Langenbecks Arch Surg. 2007;392(1):99-104. 160. Udwadia TE. One world, one people, one surgery. Surg Endosc. 2001;15(4):37-343. 161. Vargas G, Price RR, Sergelen O, Lkhagvabayar B, Batcholuun P, Enkhamagalan T. A successful model for laparoscopic train-ing in Mongolia. Int Surg. 2012;97(4):363-371. 162. Clegg-Lamptey JN, Amponsah G. Laparoscopic cholecystec-tomy at the Korle Bu Teaching Hospital, Accra, Ghana: an initial report. West Afr J Med. 2010;29(2):113-116. 163. Baigrie RJ, Stupart D. Introduction of laparoscopic colorectal cancer surgery in developing nations. Br J Surg. 2010;97(5):625-627. 164. Udwadia TE. Low-cost laparoscopic cholecystectomy. (Br J Surg. 2002; 89:1602-1607). Br J | Surgery_Schwartz. surgical equipment in international health programs. Int J Gynaecol Obstet. 1986;24(1):53-60.Brunicardi_Ch49_p2077-p2112.indd 211013/02/19 5:54 PM 2111GLOBAL SURGERYCHAPTER 49 159. Udwadia TE. Navigating laparoscopic surgery into the next decade in developing countries—a personal perspec-tive. Langenbecks Arch Surg. 2007;392(1):99-104. 160. Udwadia TE. One world, one people, one surgery. Surg Endosc. 2001;15(4):37-343. 161. Vargas G, Price RR, Sergelen O, Lkhagvabayar B, Batcholuun P, Enkhamagalan T. A successful model for laparoscopic train-ing in Mongolia. Int Surg. 2012;97(4):363-371. 162. Clegg-Lamptey JN, Amponsah G. Laparoscopic cholecystec-tomy at the Korle Bu Teaching Hospital, Accra, Ghana: an initial report. West Afr J Med. 2010;29(2):113-116. 163. Baigrie RJ, Stupart D. Introduction of laparoscopic colorectal cancer surgery in developing nations. Br J Surg. 2010;97(5):625-627. 164. Udwadia TE. Low-cost laparoscopic cholecystectomy. (Br J Surg. 2002; 89:1602-1607). Br J | [
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Surgery_Schwartz_13760 | Surgery_Schwartz | of laparoscopic colorectal cancer surgery in developing nations. Br J Surg. 2010;97(5):625-627. 164. Udwadia TE. Low-cost laparoscopic cholecystectomy. (Br J Surg. 2002; 89:1602-1607). Br J Surg. 2003;90(6):761. 165. Piukala S. Laparoscopic cholecystectomy: complications and experiences in Tonga. Pac Health Dialog. 2006;13(2): 107-110. 166. Udwadia TE, Udwadia RT, Menon K, et al. Laparoscopic sur-gery in the developing world. An overview of the Indian scene. Int Surg. 1995;80(4):371-375. 167. Akporiaye L. Trigen survey: West African College of Sur-geons. Trigen, Lagos, Nigeria. Unpublished data. 2010. 168. Al-Bazzaz PH. Kidney transplantation in Erbil, Iraq: a single-center experience. Saudi J Kidney Dis Transpl. 2010;21(2):359-362. 169. Basinda SL, Maro EE, McLarty DG, Young AE, Wing AJ. Ten Tanzanian transplants: problems and perspectives. Postgrad Med J. 1988;64(756):778-782. 170. Korle-Bu to begin kidney transplant in last quarter. 2012. Available at: | Surgery_Schwartz. of laparoscopic colorectal cancer surgery in developing nations. Br J Surg. 2010;97(5):625-627. 164. Udwadia TE. Low-cost laparoscopic cholecystectomy. (Br J Surg. 2002; 89:1602-1607). Br J Surg. 2003;90(6):761. 165. Piukala S. Laparoscopic cholecystectomy: complications and experiences in Tonga. Pac Health Dialog. 2006;13(2): 107-110. 166. Udwadia TE, Udwadia RT, Menon K, et al. Laparoscopic sur-gery in the developing world. An overview of the Indian scene. Int Surg. 1995;80(4):371-375. 167. Akporiaye L. Trigen survey: West African College of Sur-geons. Trigen, Lagos, Nigeria. Unpublished data. 2010. 168. Al-Bazzaz PH. Kidney transplantation in Erbil, Iraq: a single-center experience. Saudi J Kidney Dis Transpl. 2010;21(2):359-362. 169. Basinda SL, Maro EE, McLarty DG, Young AE, Wing AJ. Ten Tanzanian transplants: problems and perspectives. Postgrad Med J. 1988;64(756):778-782. 170. Korle-Bu to begin kidney transplant in last quarter. 2012. Available at: | [
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Surgery_Schwartz_13761 | Surgery_Schwartz | DG, Young AE, Wing AJ. Ten Tanzanian transplants: problems and perspectives. Postgrad Med J. 1988;64(756):778-782. 170. Korle-Bu to begin kidney transplant in last quarter. 2012. Available at: http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=238839. Accessed August 22, 2018. 171. Kumar A, Dubey D, Gogoi S, Arvind NK. Laparoscopy-assisted live donor nephrectomy: a modified cost-effective approach for developing countries. J Endourol. 2002;16(3):155-159. 172. Kumar A, Chaudhary H, Srivastava A, Raghavendran M. Laparoscopic live-donor nephrectomy: modifications for developing nations. BJU Int. 2004;93(9):1291-1295. 173. Simforoosh N, Basiri A, Tabibi A, Shakhssalim N. Laparo-scopic donor nephrectomy—an Iranian model for developing countries: a cost-effective no-rush approach. Exp Clin Trans-plant. 2004;2(2):249-253. 174. Wells KM, Price RR, Finlayson SG, deVries CR. Fundamen-tals for establishing and maintaining an academic centre for global surgery: the University of | Surgery_Schwartz. DG, Young AE, Wing AJ. Ten Tanzanian transplants: problems and perspectives. Postgrad Med J. 1988;64(756):778-782. 170. Korle-Bu to begin kidney transplant in last quarter. 2012. Available at: http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=238839. Accessed August 22, 2018. 171. Kumar A, Dubey D, Gogoi S, Arvind NK. Laparoscopy-assisted live donor nephrectomy: a modified cost-effective approach for developing countries. J Endourol. 2002;16(3):155-159. 172. Kumar A, Chaudhary H, Srivastava A, Raghavendran M. Laparoscopic live-donor nephrectomy: modifications for developing nations. BJU Int. 2004;93(9):1291-1295. 173. Simforoosh N, Basiri A, Tabibi A, Shakhssalim N. Laparo-scopic donor nephrectomy—an Iranian model for developing countries: a cost-effective no-rush approach. Exp Clin Trans-plant. 2004;2(2):249-253. 174. Wells KM, Price RR, Finlayson SG, deVries CR. Fundamen-tals for establishing and maintaining an academic centre for global surgery: the University of | [
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Surgery_Schwartz_13762 | Surgery_Schwartz | Exp Clin Trans-plant. 2004;2(2):249-253. 174. Wells KM, Price RR, Finlayson SG, deVries CR. Fundamen-tals for establishing and maintaining an academic centre for global surgery: the University of Utah Experience. Lancet Glob Health. 2014;2(S47):47. 175. Price RR, Butler MW, deVries CR, Abdullah F. Promoting, developing, and sustaining academic global surgery programs. In: Swaroop M, Krishnaswami S, eds. Academic Global Surgery. New York: Springer International Publishing; 2016. 176. Banerjee A. Medical electives: a chance for international health. J R Soc Med. 2010;103(1):6-8. 177. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volun-teerism. J Am Coll Surg. 2009;208(2):304-312. 178. Baker TD, Weisman C, Piwoz E. U.S. physicians in international health. Report of a current survey. JAMA. 1984;251(4):502-504. 179. Busnaina I. Medical school admissions doctor. 2012. | Surgery_Schwartz. Exp Clin Trans-plant. 2004;2(2):249-253. 174. Wells KM, Price RR, Finlayson SG, deVries CR. Fundamen-tals for establishing and maintaining an academic centre for global surgery: the University of Utah Experience. Lancet Glob Health. 2014;2(S47):47. 175. Price RR, Butler MW, deVries CR, Abdullah F. Promoting, developing, and sustaining academic global surgery programs. In: Swaroop M, Krishnaswami S, eds. Academic Global Surgery. New York: Springer International Publishing; 2016. 176. Banerjee A. Medical electives: a chance for international health. J R Soc Med. 2010;103(1):6-8. 177. Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volun-teerism. J Am Coll Surg. 2009;208(2):304-312. 178. Baker TD, Weisman C, Piwoz E. U.S. physicians in international health. Report of a current survey. JAMA. 1984;251(4):502-504. 179. Busnaina I. Medical school admissions doctor. 2012. | [
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Surgery_Schwartz_13766 | Surgery_Schwartz | JS, Hoffenberg R. The ethics of organ transplanta-tion reconsidered: paid organ donation and the use of executed prisoners as donors. Kidney Int. 1999;55(2):724-732. 192. International Surgery Canada. Telementoring in Botswana. Available at: http://internationalsurgerycanada.com/telemen-toring-in-botswana. Accessed August 22, 2018. 193. Okrainec A, Henao O, Azzie G. Telesimulation: an effec-tive method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc. 2010;24(2):417-422. 194. Henao O, Escallon J, Green J, et al. Fundamentals of lapa-roscopic surgery in Colombia using telesimulation: an effective educational tool for distance learning. Biomedica. 2013;33(1):107-114. 195. Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription. New York: McGraw-Hill; 2009:441. 196. Beck M. New low-cost surgical tool could help patients in third world. The Wall Street Journal. September 23, 2016. 197. Ng-Kamstra JS, Greenberg SLM, Abdullah F, | Surgery_Schwartz. JS, Hoffenberg R. The ethics of organ transplanta-tion reconsidered: paid organ donation and the use of executed prisoners as donors. Kidney Int. 1999;55(2):724-732. 192. International Surgery Canada. Telementoring in Botswana. Available at: http://internationalsurgerycanada.com/telemen-toring-in-botswana. Accessed August 22, 2018. 193. Okrainec A, Henao O, Azzie G. Telesimulation: an effec-tive method for teaching the fundamentals of laparoscopic surgery in resource-restricted countries. Surg Endosc. 2010;24(2):417-422. 194. Henao O, Escallon J, Green J, et al. Fundamentals of lapa-roscopic surgery in Colombia using telesimulation: an effective educational tool for distance learning. Biomedica. 2013;33(1):107-114. 195. Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription. New York: McGraw-Hill; 2009:441. 196. Beck M. New low-cost surgical tool could help patients in third world. The Wall Street Journal. September 23, 2016. 197. Ng-Kamstra JS, Greenberg SLM, Abdullah F, | [
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Surgery_Schwartz_13769 | Surgery_Schwartz | ENHANCED RECOVERY AFTER SURGERYHistory and Overview of Enhanced RecoveryAs anesthetic techniques, antibiotics, and minimally invasive surgery have improved surgical care over the centuries, fur-ther strategies to continue to improve patient outcomes have emerged. A novel perioperative regimen for patients following colon surgery using early oral nutrition, early mobilization, and epidural analgesia was first described in 1995 by Professor Hen-rik Kehlet from Copenhagen, Denmark in a small group of nine patients.1 He subsequently outlined a more detailed multimodal approach to perioperative care in 1997, reducing length of stay to a median of 2 days following sigmoid resection, and thus, has been described as the founder of enhanced recovery after surgery (ERAS).2,3 Soon thereafter, several others duplicated that applying standard perioperative care protocols could reduce length of stay following colon surgery.4The ERAS Study Group was founded in 2001 by Professor Ken Fearon and | Surgery_Schwartz. ENHANCED RECOVERY AFTER SURGERYHistory and Overview of Enhanced RecoveryAs anesthetic techniques, antibiotics, and minimally invasive surgery have improved surgical care over the centuries, fur-ther strategies to continue to improve patient outcomes have emerged. A novel perioperative regimen for patients following colon surgery using early oral nutrition, early mobilization, and epidural analgesia was first described in 1995 by Professor Hen-rik Kehlet from Copenhagen, Denmark in a small group of nine patients.1 He subsequently outlined a more detailed multimodal approach to perioperative care in 1997, reducing length of stay to a median of 2 days following sigmoid resection, and thus, has been described as the founder of enhanced recovery after surgery (ERAS).2,3 Soon thereafter, several others duplicated that applying standard perioperative care protocols could reduce length of stay following colon surgery.4The ERAS Study Group was founded in 2001 by Professor Ken Fearon and | [
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Surgery_Schwartz_13770 | Surgery_Schwartz | several others duplicated that applying standard perioperative care protocols could reduce length of stay following colon surgery.4The ERAS Study Group was founded in 2001 by Professor Ken Fearon and Professor Olle Ljungqvist to further expand on the ideas proposed by Professor Kehlet. As there was a great discrepancy between actual practices and evidence-based best practices, as well as geographical and practitioner variations in care, the group desired to create a consensus on best practices with guidelines that could be employed in the clinical arena. The primary goal of ERAS is to treat the surgical patient in a multidisciplinary team approach throughout the perioperative course with the unified goal of accelerating functional recov-ery and optimizing patient outcomes based on evidence-based medicine (Fig. 50-1).In order to develop the key tenets of ERAS, the details of preoperative care, intraoperative surgical and anesthetic tech-nique, and postoperative care were scrutinized | Surgery_Schwartz. several others duplicated that applying standard perioperative care protocols could reduce length of stay following colon surgery.4The ERAS Study Group was founded in 2001 by Professor Ken Fearon and Professor Olle Ljungqvist to further expand on the ideas proposed by Professor Kehlet. As there was a great discrepancy between actual practices and evidence-based best practices, as well as geographical and practitioner variations in care, the group desired to create a consensus on best practices with guidelines that could be employed in the clinical arena. The primary goal of ERAS is to treat the surgical patient in a multidisciplinary team approach throughout the perioperative course with the unified goal of accelerating functional recov-ery and optimizing patient outcomes based on evidence-based medicine (Fig. 50-1).In order to develop the key tenets of ERAS, the details of preoperative care, intraoperative surgical and anesthetic tech-nique, and postoperative care were scrutinized | [
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Surgery_Schwartz_13771 | Surgery_Schwartz | medicine (Fig. 50-1).In order to develop the key tenets of ERAS, the details of preoperative care, intraoperative surgical and anesthetic tech-nique, and postoperative care were scrutinized and standards for each facet of care were developed (Fig. 50-2).ERAS and its associated principles truly represented a paradigm shift in perioperative care, breaking from the clas-sical teaching of prolonged fasting postoperatively until signs of bowel function, excessive fluid administration, and delayed postoperative mobilization. Instead, mitigating the metabolic and stress responses to surgery through multimodal care and uti-lizing evidenced based medicine allows for “fast-track” recov-ery and improved outcomes.Each facet of perioperative care may have modest benefit to the patient when applied alone, but when an integrated, mul-timodal enhanced recovery pathway (ERP) is used, the benefi-cial effects become synergistic. Patients return to presurgical functional states faster, spend less time in | Surgery_Schwartz. medicine (Fig. 50-1).In order to develop the key tenets of ERAS, the details of preoperative care, intraoperative surgical and anesthetic tech-nique, and postoperative care were scrutinized and standards for each facet of care were developed (Fig. 50-2).ERAS and its associated principles truly represented a paradigm shift in perioperative care, breaking from the clas-sical teaching of prolonged fasting postoperatively until signs of bowel function, excessive fluid administration, and delayed postoperative mobilization. Instead, mitigating the metabolic and stress responses to surgery through multimodal care and uti-lizing evidenced based medicine allows for “fast-track” recov-ery and improved outcomes.Each facet of perioperative care may have modest benefit to the patient when applied alone, but when an integrated, mul-timodal enhanced recovery pathway (ERP) is used, the benefi-cial effects become synergistic. Patients return to presurgical functional states faster, spend less time in | [
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Surgery_Schwartz_13772 | Surgery_Schwartz | but when an integrated, mul-timodal enhanced recovery pathway (ERP) is used, the benefi-cial effects become synergistic. Patients return to presurgical functional states faster, spend less time in the hospital, and expe-rience less morbidity.5 Furthermore, resource utilization is reduced, healthcare system cost is less, and societal cost is lower with faster return to work and reduced homecare needs.6 Though initial studies of ERP were primarily performed for colorectal surgery, ERP can be applied to a wide variety of specialties in the inpatient and outpatient setting including urology, orthopedics, and gynecology. Preoperative OptimizationFirst proposed in 1949 by the anesthesiologist, Dr. J. Albert Lee, a preanesthetic and presurgical evaluation by an anesthesiolo-gist is associated with improved outcomes for the efficiency of the operating room, the hospital, and most importantly, the patient.7 The use of a preoperative evaluation results in identify-ing patients at elevated | Surgery_Schwartz. but when an integrated, mul-timodal enhanced recovery pathway (ERP) is used, the benefi-cial effects become synergistic. Patients return to presurgical functional states faster, spend less time in the hospital, and expe-rience less morbidity.5 Furthermore, resource utilization is reduced, healthcare system cost is less, and societal cost is lower with faster return to work and reduced homecare needs.6 Though initial studies of ERP were primarily performed for colorectal surgery, ERP can be applied to a wide variety of specialties in the inpatient and outpatient setting including urology, orthopedics, and gynecology. Preoperative OptimizationFirst proposed in 1949 by the anesthesiologist, Dr. J. Albert Lee, a preanesthetic and presurgical evaluation by an anesthesiolo-gist is associated with improved outcomes for the efficiency of the operating room, the hospital, and most importantly, the patient.7 The use of a preoperative evaluation results in identify-ing patients at elevated | [
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Surgery_Schwartz_13773 | Surgery_Schwartz | with improved outcomes for the efficiency of the operating room, the hospital, and most importantly, the patient.7 The use of a preoperative evaluation results in identify-ing patients at elevated respiratory risk, a 55% decrease in pre-operative testing, an 88% reduction in case cancellations, reduction in day of surgery delays, reduced total length of stay, a positive impact on hospital finances with cost reduction, and lower in-hospital mortality.8-13 Therefore, while it is very impor-tant for the surgeon to see the patient prior to a surgery, it is also 1Optimizing Perioperative Care: Enhanced Recovery and Chinese MedicineJennifer Holder-Murray, Stephen Esper, Zhiliang Wang, Zhigang Cui, and Xima Wang 50chapterEnhanced Recovery after Surgery 2113History and Overview of Enhanced Recovery / 2113Preoperative Optimization / 2113Metabolic Stress Response to Surgery / 2116Preoperative Fasting and Preoperative Carbohydrate Loading / 2117Intraoperative Considerations / 2117Perioperative | Surgery_Schwartz. with improved outcomes for the efficiency of the operating room, the hospital, and most importantly, the patient.7 The use of a preoperative evaluation results in identify-ing patients at elevated respiratory risk, a 55% decrease in pre-operative testing, an 88% reduction in case cancellations, reduction in day of surgery delays, reduced total length of stay, a positive impact on hospital finances with cost reduction, and lower in-hospital mortality.8-13 Therefore, while it is very impor-tant for the surgeon to see the patient prior to a surgery, it is also 1Optimizing Perioperative Care: Enhanced Recovery and Chinese MedicineJennifer Holder-Murray, Stephen Esper, Zhiliang Wang, Zhigang Cui, and Xima Wang 50chapterEnhanced Recovery after Surgery 2113History and Overview of Enhanced Recovery / 2113Preoperative Optimization / 2113Metabolic Stress Response to Surgery / 2116Preoperative Fasting and Preoperative Carbohydrate Loading / 2117Intraoperative Considerations / 2117Perioperative | [
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Surgery_Schwartz_13774 | Surgery_Schwartz | / 2113Preoperative Optimization / 2113Metabolic Stress Response to Surgery / 2116Preoperative Fasting and Preoperative Carbohydrate Loading / 2117Intraoperative Considerations / 2117Perioperative Pain Management / 2119Postoperative Nausea and Vomiting Prevention / 2121Early Nutrition and Postoperative Ileus Prevention / 2121Mobilization / 2122ERAS in CRS / 2122ERAS in Hepatopancreaticobiliary Surgery / 2123ERAS in Gastrectomy and Esophagectomy / 2123ERAS in Bariatric Surgery / 2123ERAS in Other Surgical Specialties / 2123Setting Up an ERAS Program / 2124Traditional Chinese Medicine in Surgical Patients 2124History of Traditional Chinese Medicine / 2124Preoperative Nutritional Optimization / 2126Bowel Preparation for Surgery / 2126Preoperative Optimization During Sepsis and Infection / 2126Perioperative Pain Management / 2127Postoperative Nausea and Vomiting Prevention / 2127Early Nutrition and Postoperative Ileus Prevention / 2127Traditional Chinese Medicine in Common Surgical | Surgery_Schwartz. / 2113Preoperative Optimization / 2113Metabolic Stress Response to Surgery / 2116Preoperative Fasting and Preoperative Carbohydrate Loading / 2117Intraoperative Considerations / 2117Perioperative Pain Management / 2119Postoperative Nausea and Vomiting Prevention / 2121Early Nutrition and Postoperative Ileus Prevention / 2121Mobilization / 2122ERAS in CRS / 2122ERAS in Hepatopancreaticobiliary Surgery / 2123ERAS in Gastrectomy and Esophagectomy / 2123ERAS in Bariatric Surgery / 2123ERAS in Other Surgical Specialties / 2123Setting Up an ERAS Program / 2124Traditional Chinese Medicine in Surgical Patients 2124History of Traditional Chinese Medicine / 2124Preoperative Nutritional Optimization / 2126Bowel Preparation for Surgery / 2126Preoperative Optimization During Sepsis and Infection / 2126Perioperative Pain Management / 2127Postoperative Nausea and Vomiting Prevention / 2127Early Nutrition and Postoperative Ileus Prevention / 2127Traditional Chinese Medicine in Common Surgical | [
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Surgery_Schwartz_13775 | Surgery_Schwartz | / 2126Perioperative Pain Management / 2127Postoperative Nausea and Vomiting Prevention / 2127Early Nutrition and Postoperative Ileus Prevention / 2127Traditional Chinese Medicine in Common Surgical Conditions / 2127Brunicardi_Ch50_p2113-p2136.indd 211301/03/19 9:39 AM 2114Key Points1 Enhanced recovery after surgery (ERAS) is a paradigm shift in the surgical care of patients. As a multimodal, integrated, evidence-based care pathway, ERAS optimizes patient care in the preoperative, intraoperative, and post-operative setting in order to achieve best patient outcomes. Patients recover faster, experience less physiological stress, enjoy shorter stays in the hospital, and have fewer complications.2 Setting appropriate expectations, optimizing nutritional and physical status through prehabilitation, and treating medical comorbidities optimizes patients before surgery.3 Achieving normovolemia both intraoperatively and post-operatively is important in order to maintain perfusion without | Surgery_Schwartz. / 2126Perioperative Pain Management / 2127Postoperative Nausea and Vomiting Prevention / 2127Early Nutrition and Postoperative Ileus Prevention / 2127Traditional Chinese Medicine in Common Surgical Conditions / 2127Brunicardi_Ch50_p2113-p2136.indd 211301/03/19 9:39 AM 2114Key Points1 Enhanced recovery after surgery (ERAS) is a paradigm shift in the surgical care of patients. As a multimodal, integrated, evidence-based care pathway, ERAS optimizes patient care in the preoperative, intraoperative, and post-operative setting in order to achieve best patient outcomes. Patients recover faster, experience less physiological stress, enjoy shorter stays in the hospital, and have fewer complications.2 Setting appropriate expectations, optimizing nutritional and physical status through prehabilitation, and treating medical comorbidities optimizes patients before surgery.3 Achieving normovolemia both intraoperatively and post-operatively is important in order to maintain perfusion without | [
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Surgery_Schwartz_13776 | Surgery_Schwartz | and treating medical comorbidities optimizes patients before surgery.3 Achieving normovolemia both intraoperatively and post-operatively is important in order to maintain perfusion without volume overload, as hypervolemia and hypovo-lemia are both associated with significant complications. Goal-directed therapy approaches maintain normovolemia with zero fluid balance.4 Intravenous normal saline administration results in hyper-chloremia, which has been associated with increased mor-tality and morbidity.5 As pain is a subjective response and cannot therefore be experienced while unconscious, the use of opioids intraop-eratively should generally be avoided in order to minimize the multiorgan system side effects of these medications. Additionally, avoiding intraoperative opioids actually improves postoperative pain scores and reduces the need for postoperative opioids.6 Multimodal analgesia, which includes oral or IV nonopioid analgesia and regional analgesic techniques, can reduce | Surgery_Schwartz. and treating medical comorbidities optimizes patients before surgery.3 Achieving normovolemia both intraoperatively and post-operatively is important in order to maintain perfusion without volume overload, as hypervolemia and hypovo-lemia are both associated with significant complications. Goal-directed therapy approaches maintain normovolemia with zero fluid balance.4 Intravenous normal saline administration results in hyper-chloremia, which has been associated with increased mor-tality and morbidity.5 As pain is a subjective response and cannot therefore be experienced while unconscious, the use of opioids intraop-eratively should generally be avoided in order to minimize the multiorgan system side effects of these medications. Additionally, avoiding intraoperative opioids actually improves postoperative pain scores and reduces the need for postoperative opioids.6 Multimodal analgesia, which includes oral or IV nonopioid analgesia and regional analgesic techniques, can reduce | [
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Surgery_Schwartz_13777 | Surgery_Schwartz | improves postoperative pain scores and reduces the need for postoperative opioids.6 Multimodal analgesia, which includes oral or IV nonopioid analgesia and regional analgesic techniques, can reduce postoperative physiological stress and decrease complica-tions associated with surgery as part of a pain management regimen. Multimodal analgesia has been shown to reduce the number of opioids required for analgesia.7 The strategies for avoiding postoperative nausea and vom-iting include the avoidance of general anesthesia, the use of totally intravenous anesthesia, avoidance of nitrous oxide and volatile agents, minimizing intraoperative and postoperative opioids, and adequate hydration.8 Enhanced recovery after surgery care pathways can be applied to numerous types of surgery including colorectal, liver, pancreas, bariatric, gynecologic, and urologic sur-gery with success.9 Traditional Chinese medicine has been practiced for thou-sands of years and serves as a distinct cultural heritage | Surgery_Schwartz. improves postoperative pain scores and reduces the need for postoperative opioids.6 Multimodal analgesia, which includes oral or IV nonopioid analgesia and regional analgesic techniques, can reduce postoperative physiological stress and decrease complica-tions associated with surgery as part of a pain management regimen. Multimodal analgesia has been shown to reduce the number of opioids required for analgesia.7 The strategies for avoiding postoperative nausea and vom-iting include the avoidance of general anesthesia, the use of totally intravenous anesthesia, avoidance of nitrous oxide and volatile agents, minimizing intraoperative and postoperative opioids, and adequate hydration.8 Enhanced recovery after surgery care pathways can be applied to numerous types of surgery including colorectal, liver, pancreas, bariatric, gynecologic, and urologic sur-gery with success.9 Traditional Chinese medicine has been practiced for thou-sands of years and serves as a distinct cultural heritage | [
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Surgery_Schwartz_13778 | Surgery_Schwartz | liver, pancreas, bariatric, gynecologic, and urologic sur-gery with success.9 Traditional Chinese medicine has been practiced for thou-sands of years and serves as a distinct cultural heritage of China. Its unique theories and methods are still applied widely in the practice of modern medicine, including dis-ease prevention, disease treatment, and perioperative management.10 Acupuncture and transcutaneous electroacupuncture can reduce the number of opioids utilized in the perioperative setting. Additionally, acupuncture, transcutaneous elec-troacupuncture, and some Chinese herb decoctions are effective in the prevention and treatment of postoperative nausea and vomiting.highly important for the patient to have an opportunity to dis-cuss the upcoming perisurgical and perianesthetic experience with a physician that is trained in the realm of periopera-tive optimization. Setting Expectations and Patient Education. Setting expectations in the preoperative clinic helps to orient patients | Surgery_Schwartz. liver, pancreas, bariatric, gynecologic, and urologic sur-gery with success.9 Traditional Chinese medicine has been practiced for thou-sands of years and serves as a distinct cultural heritage of China. Its unique theories and methods are still applied widely in the practice of modern medicine, including dis-ease prevention, disease treatment, and perioperative management.10 Acupuncture and transcutaneous electroacupuncture can reduce the number of opioids utilized in the perioperative setting. Additionally, acupuncture, transcutaneous elec-troacupuncture, and some Chinese herb decoctions are effective in the prevention and treatment of postoperative nausea and vomiting.highly important for the patient to have an opportunity to dis-cuss the upcoming perisurgical and perianesthetic experience with a physician that is trained in the realm of periopera-tive optimization. Setting Expectations and Patient Education. Setting expectations in the preoperative clinic helps to orient patients | [
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Surgery_Schwartz_13779 | Surgery_Schwartz | with a physician that is trained in the realm of periopera-tive optimization. Setting Expectations and Patient Education. Setting expectations in the preoperative clinic helps to orient patients regarding the entire surgical experience, from what they are expected to do at home before the surgery to the entire length of the recovery both in the hospital and at home. Information on the procedure and typical recovery should be clear, well defined, and consistently reinforced from all healthcare person-nel that interact with the patient. Clear expectations of goals prior to surgery, in the hospital, and after discharge should be communicated long before the surgery. Expected length of stay and disposition should also be clearly communicated in order to optimize timely discharge. The preoperative clinic helps in this role and to establish the patient as the leader in his or her own care. The patient must understand that his or her active partici-pation throughout the perioperative | Surgery_Schwartz. with a physician that is trained in the realm of periopera-tive optimization. Setting Expectations and Patient Education. Setting expectations in the preoperative clinic helps to orient patients regarding the entire surgical experience, from what they are expected to do at home before the surgery to the entire length of the recovery both in the hospital and at home. Information on the procedure and typical recovery should be clear, well defined, and consistently reinforced from all healthcare person-nel that interact with the patient. Clear expectations of goals prior to surgery, in the hospital, and after discharge should be communicated long before the surgery. Expected length of stay and disposition should also be clearly communicated in order to optimize timely discharge. The preoperative clinic helps in this role and to establish the patient as the leader in his or her own care. The patient must understand that his or her active partici-pation throughout the perioperative | [
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Surgery_Schwartz_13780 | Surgery_Schwartz | clinic helps in this role and to establish the patient as the leader in his or her own care. The patient must understand that his or her active partici-pation throughout the perioperative experience will facilitate the recovery. A surgeon can do an operation. An anesthesiologist can keep a patient alive while the patient asleep. However, in reality, it is up to the patient to make his or her own care a prior-ity. If individuals train for a race, should they not also prepare for their procedure so that the recovery is swift? The optimiza-tion for success at surgery begins preoperatively with smoking cessation, exercise, and nutrition, but it also continues in the hospital and after discharge with pain control, physical activ-ity, discharge planning, and returning to daily activities. Clear expectations at each point in the perioperative continuum, which are communicated to the patient, will improve the perioperative experience for the patient and the provider.According to Costa, | Surgery_Schwartz. clinic helps in this role and to establish the patient as the leader in his or her own care. The patient must understand that his or her active partici-pation throughout the perioperative experience will facilitate the recovery. A surgeon can do an operation. An anesthesiologist can keep a patient alive while the patient asleep. However, in reality, it is up to the patient to make his or her own care a prior-ity. If individuals train for a race, should they not also prepare for their procedure so that the recovery is swift? The optimiza-tion for success at surgery begins preoperatively with smoking cessation, exercise, and nutrition, but it also continues in the hospital and after discharge with pain control, physical activ-ity, discharge planning, and returning to daily activities. Clear expectations at each point in the perioperative continuum, which are communicated to the patient, will improve the perioperative experience for the patient and the provider.According to Costa, | [
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Surgery_Schwartz_13781 | Surgery_Schwartz | Clear expectations at each point in the perioperative continuum, which are communicated to the patient, will improve the perioperative experience for the patient and the provider.According to Costa, “Evidence shows that patients suffer needlessly due to inadequate preoperative preparation and lack of information regarding their postoperative course as indicated by reports of unexpected pain, fatigue, and the inability to care for oneself.”14 Patients enter physician offices and procedures with a great deal of fear and anxiety related to the identification of a disease, the consequences of treatment of this disease, and/or the fear of death. Eliciting the patient’s concerns and provid-ing optimal communication and education can allay much of this fear and anxiety. There is a substantial perioperative cul-ture change that is brought about by the elements of ERAS, and many patients have personally had or have had a close relative that has experienced surgery that likely did not include | Surgery_Schwartz. Clear expectations at each point in the perioperative continuum, which are communicated to the patient, will improve the perioperative experience for the patient and the provider.According to Costa, “Evidence shows that patients suffer needlessly due to inadequate preoperative preparation and lack of information regarding their postoperative course as indicated by reports of unexpected pain, fatigue, and the inability to care for oneself.”14 Patients enter physician offices and procedures with a great deal of fear and anxiety related to the identification of a disease, the consequences of treatment of this disease, and/or the fear of death. Eliciting the patient’s concerns and provid-ing optimal communication and education can allay much of this fear and anxiety. There is a substantial perioperative cul-ture change that is brought about by the elements of ERAS, and many patients have personally had or have had a close relative that has experienced surgery that likely did not include | [
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Surgery_Schwartz_13782 | Surgery_Schwartz | cul-ture change that is brought about by the elements of ERAS, and many patients have personally had or have had a close relative that has experienced surgery that likely did not include many 2ERAS: Team-centered approachPatientSurgical teamPreoperative nursing teamAnesthesiology teamPACU nursing teamInpatient nursing teamOffice/clinic teamERAS educatorPharmacyERAS project managerInformation technological teamFigure 50-1. Enhanced recovery multidisciplinary team. ERAS = enhanced recovery after surgery; PACU = postanesthesia care unit.Brunicardi_Ch50_p2113-p2136.indd 211401/03/19 9:39 AM 2115OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50components of ERAS. Therefore, this culture change must be clearly disseminated to the patients and include new fasting guidelines, analgesic management, and patient participation in preoperative optimization. Patients can then anticipate and plan for certain events and sensations, such as what and when to eat and | Surgery_Schwartz. cul-ture change that is brought about by the elements of ERAS, and many patients have personally had or have had a close relative that has experienced surgery that likely did not include many 2ERAS: Team-centered approachPatientSurgical teamPreoperative nursing teamAnesthesiology teamPACU nursing teamInpatient nursing teamOffice/clinic teamERAS educatorPharmacyERAS project managerInformation technological teamFigure 50-1. Enhanced recovery multidisciplinary team. ERAS = enhanced recovery after surgery; PACU = postanesthesia care unit.Brunicardi_Ch50_p2113-p2136.indd 211401/03/19 9:39 AM 2115OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50components of ERAS. Therefore, this culture change must be clearly disseminated to the patients and include new fasting guidelines, analgesic management, and patient participation in preoperative optimization. Patients can then anticipate and plan for certain events and sensations, such as what and when to eat and | [
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Surgery_Schwartz_13783 | Surgery_Schwartz | guidelines, analgesic management, and patient participation in preoperative optimization. Patients can then anticipate and plan for certain events and sensations, such as what and when to eat and drink, how to exercise, what medications will be used, what tubes or lines will be present, and what criteria are used for dis-charge and return to daily activities. This kind of teaching has been defined as a therapeutic communication to help the patient face and cope with the surgical procedure in a calm manner.15Approximately 90 million people have difficulty under-standing and subsequently acting upon health information dis-tributed to them.16 Further, the ability of patients to process and understand basic information to make appropriate health decisions is directly related to socioeconomic status and to Caucasian race; furthermore, the readability of patient-directed healthcare material may be too advanced for comprehension by much of the surgical population.17,18 Thus, it is | Surgery_Schwartz. guidelines, analgesic management, and patient participation in preoperative optimization. Patients can then anticipate and plan for certain events and sensations, such as what and when to eat and drink, how to exercise, what medications will be used, what tubes or lines will be present, and what criteria are used for dis-charge and return to daily activities. This kind of teaching has been defined as a therapeutic communication to help the patient face and cope with the surgical procedure in a calm manner.15Approximately 90 million people have difficulty under-standing and subsequently acting upon health information dis-tributed to them.16 Further, the ability of patients to process and understand basic information to make appropriate health decisions is directly related to socioeconomic status and to Caucasian race; furthermore, the readability of patient-directed healthcare material may be too advanced for comprehension by much of the surgical population.17,18 Thus, it is | [
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Surgery_Schwartz_13784 | Surgery_Schwartz | status and to Caucasian race; furthermore, the readability of patient-directed healthcare material may be too advanced for comprehension by much of the surgical population.17,18 Thus, it is appropriate for patient information material to be at no higher than a sixth grade reading level, friendly, clear, concise, and simply designed. The employment of audiovisual aids may assist some patients as well.Nutrition. Surgery results in a significant catabolic stress response on the body, triggering inflammation and nutrient depletion. This stress response results in downstream effects on numerous organ systems and can lead to a higher risk of post-operative complications. Ensuring preoperative adequate nutri-tion is imperative before a large surgical procedure in order to mitigate adverse outcomes.While enteral or parenteral nutritional supplementation can be considered for the most nutritionally compromised patient, the enteral route is always preferred if clinically appropriate and can be | Surgery_Schwartz. status and to Caucasian race; furthermore, the readability of patient-directed healthcare material may be too advanced for comprehension by much of the surgical population.17,18 Thus, it is appropriate for patient information material to be at no higher than a sixth grade reading level, friendly, clear, concise, and simply designed. The employment of audiovisual aids may assist some patients as well.Nutrition. Surgery results in a significant catabolic stress response on the body, triggering inflammation and nutrient depletion. This stress response results in downstream effects on numerous organ systems and can lead to a higher risk of post-operative complications. Ensuring preoperative adequate nutri-tion is imperative before a large surgical procedure in order to mitigate adverse outcomes.While enteral or parenteral nutritional supplementation can be considered for the most nutritionally compromised patient, the enteral route is always preferred if clinically appropriate and can be | [
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Surgery_Schwartz_13785 | Surgery_Schwartz | enteral or parenteral nutritional supplementation can be considered for the most nutritionally compromised patient, the enteral route is always preferred if clinically appropriate and can be adequately achieved in a timely fashion. Two main approaches to preoperative enteral nutrition include standard oral nutrition supplements and immunonutrition supplements, each providing extra protein and calories to supplement the diet. There is no statistical difference in infections, complications, and length of hospital stay between patients given standard oral versus immunonutrition supplements.19Standard oral nutrition products are high in protein, contain vitamins and minerals, and are widely available. Immunonutrition supplements usually similarly contain high protein, vitamins, and minerals, but they also have the addition of arginine to improve immunity and tissue repair and omega-3 fatty acids to mediate the inflammatory response.19 The exact dosage of arginine and omega-3 fatty acids | Surgery_Schwartz. enteral or parenteral nutritional supplementation can be considered for the most nutritionally compromised patient, the enteral route is always preferred if clinically appropriate and can be adequately achieved in a timely fashion. Two main approaches to preoperative enteral nutrition include standard oral nutrition supplements and immunonutrition supplements, each providing extra protein and calories to supplement the diet. There is no statistical difference in infections, complications, and length of hospital stay between patients given standard oral versus immunonutrition supplements.19Standard oral nutrition products are high in protein, contain vitamins and minerals, and are widely available. Immunonutrition supplements usually similarly contain high protein, vitamins, and minerals, but they also have the addition of arginine to improve immunity and tissue repair and omega-3 fatty acids to mediate the inflammatory response.19 The exact dosage of arginine and omega-3 fatty acids | [
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Surgery_Schwartz_13786 | Surgery_Schwartz | but they also have the addition of arginine to improve immunity and tissue repair and omega-3 fatty acids to mediate the inflammatory response.19 The exact dosage of arginine and omega-3 fatty acids that contribute to improved outcomes is not known. Standard oral nutrition prod-ucts may contain no or lesser quantities of arginine and omega-3 fatty acids when compared to immunonutrition supplements. The exact duration and frequency of supplementation have not been established; however, it is clear that the use of standard oral nutrition products has a positive impact on surgical out-comes by reducing postsurgical complications.19Exercise and Prehabilitation. Prehabilitation is defined as “the process of enhancing the functional capacity of the indi-vidual to enable him or her to withstand a stressful event.”20,21 Both exercise and prehabilitation, which have, heretofore, focused on cardiopulmonary rehabilitation prior to surgery, are very important to optimization of patient outcomes. | Surgery_Schwartz. but they also have the addition of arginine to improve immunity and tissue repair and omega-3 fatty acids to mediate the inflammatory response.19 The exact dosage of arginine and omega-3 fatty acids that contribute to improved outcomes is not known. Standard oral nutrition prod-ucts may contain no or lesser quantities of arginine and omega-3 fatty acids when compared to immunonutrition supplements. The exact duration and frequency of supplementation have not been established; however, it is clear that the use of standard oral nutrition products has a positive impact on surgical out-comes by reducing postsurgical complications.19Exercise and Prehabilitation. Prehabilitation is defined as “the process of enhancing the functional capacity of the indi-vidual to enable him or her to withstand a stressful event.”20,21 Both exercise and prehabilitation, which have, heretofore, focused on cardiopulmonary rehabilitation prior to surgery, are very important to optimization of patient outcomes. | [
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Surgery_Schwartz_13787 | Surgery_Schwartz | a stressful event.”20,21 Both exercise and prehabilitation, which have, heretofore, focused on cardiopulmonary rehabilitation prior to surgery, are very important to optimization of patient outcomes. Peri-operative cardiopulmonary exercise testing and prehabilitation in relation to ERAS programs around the world have been ana-lyzed, and it is noted that a reduction in fitness prior to sur-gery is associated with increased mortality and morbidity in the postoperative arena.22 Patients who actively exercise even when suffering from documented coronary artery disease, heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, depression, dementia, cancer, and stroke have better outcomes.23-36 Furthermore, other literature supports the signifi-cant merits of exercise therapy and cardiopulmonary exercise therapy before and after major surgery, with the ability to reduce infection, hospital-associated complications, length of stay, and postoperative mortality.37There is a | Surgery_Schwartz. a stressful event.”20,21 Both exercise and prehabilitation, which have, heretofore, focused on cardiopulmonary rehabilitation prior to surgery, are very important to optimization of patient outcomes. Peri-operative cardiopulmonary exercise testing and prehabilitation in relation to ERAS programs around the world have been ana-lyzed, and it is noted that a reduction in fitness prior to sur-gery is associated with increased mortality and morbidity in the postoperative arena.22 Patients who actively exercise even when suffering from documented coronary artery disease, heart failure, hypertension, diabetes, chronic obstructive pulmonary disease, depression, dementia, cancer, and stroke have better outcomes.23-36 Furthermore, other literature supports the signifi-cant merits of exercise therapy and cardiopulmonary exercise therapy before and after major surgery, with the ability to reduce infection, hospital-associated complications, length of stay, and postoperative mortality.37There is a | [
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Surgery_Schwartz_13788 | Surgery_Schwartz | and cardiopulmonary exercise therapy before and after major surgery, with the ability to reduce infection, hospital-associated complications, length of stay, and postoperative mortality.37There is a significant amount of evidence indicating that exercise training is feasible and safe in patients with a spec-trum of severe cardiac and pulmonary diseases as many of these patients require surgery to manage other disease processes. A randomized controlled trial involving 246 low-risk patients undergoing cardiac surgery reported a 1-day reduction in ICU stay and a reduced hospital length of stay in the intervention group.38 Cardiopulmonary fitness was found to be a strong independent predictor of survival after lung surgery, especially for non–small cell lung cancer.39 Preliminary nonrandomized Preoperative phasePatient education & set expectationsSmoking & alcohol cessationPrehabilitation with diet & exerciseShortened fastingAntimicrobial prophylaxisVTE prophylaxisMinimize bowel | Surgery_Schwartz. and cardiopulmonary exercise therapy before and after major surgery, with the ability to reduce infection, hospital-associated complications, length of stay, and postoperative mortality.37There is a significant amount of evidence indicating that exercise training is feasible and safe in patients with a spec-trum of severe cardiac and pulmonary diseases as many of these patients require surgery to manage other disease processes. A randomized controlled trial involving 246 low-risk patients undergoing cardiac surgery reported a 1-day reduction in ICU stay and a reduced hospital length of stay in the intervention group.38 Cardiopulmonary fitness was found to be a strong independent predictor of survival after lung surgery, especially for non–small cell lung cancer.39 Preliminary nonrandomized Preoperative phasePatient education & set expectationsSmoking & alcohol cessationPrehabilitation with diet & exerciseShortened fastingAntimicrobial prophylaxisVTE prophylaxisMinimize bowel | [
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Surgery_Schwartz_13789 | Surgery_Schwartz | Preoperative phasePatient education & set expectationsSmoking & alcohol cessationPrehabilitation with diet & exerciseShortened fastingAntimicrobial prophylaxisVTE prophylaxisMinimize bowel preparationIntraoperative phasePain blocksMinimally invasive surgeryGoal-directed fluid therapyMultimodal pain reliefPrevention of PONVAvoidance of tubes, drains, linesNormothermiaPostoperative phaseGoal-directed fluid therapyPrevention of PONVEarly ambulationEarly feedingMultimodal pain reliefEarly urinary catheter removalDefined discharge criteriaFigure 50-2. Phases and components of an enhanced recovery after surgery pathway. VTE = venous thromboembolism; PONV = postopera-tive nausea and vomiting.Brunicardi_Ch50_p2113-p2136.indd 211501/03/19 9:39 AM 2116SPECIFIC CONSIDERATIONSPART IIdata from patients undergoing elective rectal cancer surgery within an ERAS program have shown the feasibility of provid-ing a cardiopulmonary exercise interval training program that is delivered three times per | Surgery_Schwartz. Preoperative phasePatient education & set expectationsSmoking & alcohol cessationPrehabilitation with diet & exerciseShortened fastingAntimicrobial prophylaxisVTE prophylaxisMinimize bowel preparationIntraoperative phasePain blocksMinimally invasive surgeryGoal-directed fluid therapyMultimodal pain reliefPrevention of PONVAvoidance of tubes, drains, linesNormothermiaPostoperative phaseGoal-directed fluid therapyPrevention of PONVEarly ambulationEarly feedingMultimodal pain reliefEarly urinary catheter removalDefined discharge criteriaFigure 50-2. Phases and components of an enhanced recovery after surgery pathway. VTE = venous thromboembolism; PONV = postopera-tive nausea and vomiting.Brunicardi_Ch50_p2113-p2136.indd 211501/03/19 9:39 AM 2116SPECIFIC CONSIDERATIONSPART IIdata from patients undergoing elective rectal cancer surgery within an ERAS program have shown the feasibility of provid-ing a cardiopulmonary exercise interval training program that is delivered three times per | [
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Surgery_Schwartz_13790 | Surgery_Schwartz | undergoing elective rectal cancer surgery within an ERAS program have shown the feasibility of provid-ing a cardiopulmonary exercise interval training program that is delivered three times per week for 6 weeks in a hospital setting after neoadjuvant chemoradiotherapy and before surgery.40 The interval following neoadjuvant therapy offers a unique window of time to improve the fitness and nutrition of many oncologic patients, which is especially important as these patients can often be some of the most debilitated.The addition of physical fitness and activity to a preopera-tive regimen for elderly patients undergoing major abdominal surgery significantly improved mortality, discharge to home versus a care facility, and length of stay.41 While this study showed that patients benefited from 60-minute sessions 2 to 4 weeks prior to surgery, even brief therapy before surgery, ranging from 1 day to 7 days before major abdominal surgery, have been associate with a significant decrease in | Surgery_Schwartz. undergoing elective rectal cancer surgery within an ERAS program have shown the feasibility of provid-ing a cardiopulmonary exercise interval training program that is delivered three times per week for 6 weeks in a hospital setting after neoadjuvant chemoradiotherapy and before surgery.40 The interval following neoadjuvant therapy offers a unique window of time to improve the fitness and nutrition of many oncologic patients, which is especially important as these patients can often be some of the most debilitated.The addition of physical fitness and activity to a preopera-tive regimen for elderly patients undergoing major abdominal surgery significantly improved mortality, discharge to home versus a care facility, and length of stay.41 While this study showed that patients benefited from 60-minute sessions 2 to 4 weeks prior to surgery, even brief therapy before surgery, ranging from 1 day to 7 days before major abdominal surgery, have been associate with a significant decrease in | [
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Surgery_Schwartz_13791 | Surgery_Schwartz | 60-minute sessions 2 to 4 weeks prior to surgery, even brief therapy before surgery, ranging from 1 day to 7 days before major abdominal surgery, have been associate with a significant decrease in postopera-tive complications.42,43 Therefore, some oncologic or semiurgent patients may actually benefit from preoperative cardiopulmo-nary exercise programs.Smoking Cessation. Clearly tobacco use, especially smok-ing, has been well documented across all surgical specialties to increase postoperative mortality, as well as increase postopera-tive complications including prolonged ventilation, pneumonia, deep venous thrombosis, wound infection, delayed wound heal-ing, and reduced bone fusion.44-47 Physiologically, the carbon monoxide and nicotine from tobacco products increase heart rate and blood pressure and the body’s demand for oxygen. Nic-otine also causes vasoconstriction, reducing perfusion to many tissue beds. Obviously, it is advantageous for patients to cease smoking preoperatively. | Surgery_Schwartz. 60-minute sessions 2 to 4 weeks prior to surgery, even brief therapy before surgery, ranging from 1 day to 7 days before major abdominal surgery, have been associate with a significant decrease in postopera-tive complications.42,43 Therefore, some oncologic or semiurgent patients may actually benefit from preoperative cardiopulmo-nary exercise programs.Smoking Cessation. Clearly tobacco use, especially smok-ing, has been well documented across all surgical specialties to increase postoperative mortality, as well as increase postopera-tive complications including prolonged ventilation, pneumonia, deep venous thrombosis, wound infection, delayed wound heal-ing, and reduced bone fusion.44-47 Physiologically, the carbon monoxide and nicotine from tobacco products increase heart rate and blood pressure and the body’s demand for oxygen. Nic-otine also causes vasoconstriction, reducing perfusion to many tissue beds. Obviously, it is advantageous for patients to cease smoking preoperatively. | [
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Surgery_Schwartz_13792 | Surgery_Schwartz | pressure and the body’s demand for oxygen. Nic-otine also causes vasoconstriction, reducing perfusion to many tissue beds. Obviously, it is advantageous for patients to cease smoking preoperatively. There is debate about the duration of the nicotine free days needed preoperatively to offer best out-comes, though the literature suggests that the longer duration of smoking cessation prior to surgery portends better outcomes.48 This is likely to allow for bronchiolar and collagen remodeling and the several weeks following last exposure that are needed to achieve blood free of nicotine and its derivatives.Metabolic Stress Response to SurgeryMultiple organ systems interact in numerous metabolic and inflammatory cascades following the stress response to surgery leading to insulin resistance and protein catabolism (Fig. 50-3). Neuroendocrine responses, stress hormones cascades, activation of cytokine, and immune reactions all occur, leading to a cata-bolic state.49 Central to this metabolic | Surgery_Schwartz. pressure and the body’s demand for oxygen. Nic-otine also causes vasoconstriction, reducing perfusion to many tissue beds. Obviously, it is advantageous for patients to cease smoking preoperatively. There is debate about the duration of the nicotine free days needed preoperatively to offer best out-comes, though the literature suggests that the longer duration of smoking cessation prior to surgery portends better outcomes.48 This is likely to allow for bronchiolar and collagen remodeling and the several weeks following last exposure that are needed to achieve blood free of nicotine and its derivatives.Metabolic Stress Response to SurgeryMultiple organ systems interact in numerous metabolic and inflammatory cascades following the stress response to surgery leading to insulin resistance and protein catabolism (Fig. 50-3). Neuroendocrine responses, stress hormones cascades, activation of cytokine, and immune reactions all occur, leading to a cata-bolic state.49 Central to this metabolic | [
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Surgery_Schwartz_13793 | Surgery_Schwartz | protein catabolism (Fig. 50-3). Neuroendocrine responses, stress hormones cascades, activation of cytokine, and immune reactions all occur, leading to a cata-bolic state.49 Central to this metabolic and inflammatory cas-cade is the development of insulin resistance, whereby a normal insulin concentration results in a subnormal biologic response. As insulin is the main anabolic hormone involved in glucose control, fat metabolism, and protein balance, insulin resistance disrupts many metabolic pathways.Hyperglycemia from insulin resistance results from an increase in glucose production and a decrease in glucose uptake by the periphery. In a fed state, insulin levels surge to 6 to 8 times basal levels, which stops glucose production and increases peripheral glucose uptake threeto fourfold.50 When fasting, insulin levels remain in a relative steady state with minimal effects on glucose and protein metabolism. Even when insulin levels increase to three times basal levels, there is no | Surgery_Schwartz. protein catabolism (Fig. 50-3). Neuroendocrine responses, stress hormones cascades, activation of cytokine, and immune reactions all occur, leading to a cata-bolic state.49 Central to this metabolic and inflammatory cas-cade is the development of insulin resistance, whereby a normal insulin concentration results in a subnormal biologic response. As insulin is the main anabolic hormone involved in glucose control, fat metabolism, and protein balance, insulin resistance disrupts many metabolic pathways.Hyperglycemia from insulin resistance results from an increase in glucose production and a decrease in glucose uptake by the periphery. In a fed state, insulin levels surge to 6 to 8 times basal levels, which stops glucose production and increases peripheral glucose uptake threeto fourfold.50 When fasting, insulin levels remain in a relative steady state with minimal effects on glucose and protein metabolism. Even when insulin levels increase to three times basal levels, there is no | [
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Surgery_Schwartz_13794 | Surgery_Schwartz | When fasting, insulin levels remain in a relative steady state with minimal effects on glucose and protein metabolism. Even when insulin levels increase to three times basal levels, there is no increase in peripheral glucose uptake. Therefore, in the postoperative fast-ing state, without the assistance of exogenous insulin, peripheral Counterregulatory hormonescytokinesGlycogenolysisGlucoseLipolysisInsulinresistanceWhole-bodyprotein catabolismGluconeogenesisHypothalamusPituitaryGlycerolAmino acidsAcute-phaseproteinsHyperglycemiaPyruvateGlycolysisProteolysisLactateInjury siteAfferentsensorynervesSympathetic nervesHumoral agentsNeural impulsesFigure 50-3. Metabolic stress response to surgery results in insulin resistance. (Reproduced with permission from McGill University Health Center Patient Education Office, Montreal, Quebec, Canada.)Brunicardi_Ch50_p2113-p2136.indd 211601/03/19 9:39 AM 2117OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50glucose | Surgery_Schwartz. When fasting, insulin levels remain in a relative steady state with minimal effects on glucose and protein metabolism. Even when insulin levels increase to three times basal levels, there is no increase in peripheral glucose uptake. Therefore, in the postoperative fast-ing state, without the assistance of exogenous insulin, peripheral Counterregulatory hormonescytokinesGlycogenolysisGlucoseLipolysisInsulinresistanceWhole-bodyprotein catabolismGluconeogenesisHypothalamusPituitaryGlycerolAmino acidsAcute-phaseproteinsHyperglycemiaPyruvateGlycolysisProteolysisLactateInjury siteAfferentsensorynervesSympathetic nervesHumoral agentsNeural impulsesFigure 50-3. Metabolic stress response to surgery results in insulin resistance. (Reproduced with permission from McGill University Health Center Patient Education Office, Montreal, Quebec, Canada.)Brunicardi_Ch50_p2113-p2136.indd 211601/03/19 9:39 AM 2117OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50glucose | [
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Surgery_Schwartz_13795 | Surgery_Schwartz | Education Office, Montreal, Quebec, Canada.)Brunicardi_Ch50_p2113-p2136.indd 211601/03/19 9:39 AM 2117OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50glucose uptake is reduced. The resulting hyperglycemia can be corrected, however, with the use of exogenous insulin, and when normoglycemia is achieved in the perioperative period, the main components of metabolism also normalize.51The preoperative and postoperative fasting state triggers insulin resistance resulting in a catabolic state with gluconeo-genesis and protein breakdown. Following prolonged fasting states with stress such as following surgery, protein catabolism can be increased several fold over baseline. As less glycogen is stored in the muscle and loss of lean body mass occurs, there is less muscle function and therefore less capacity to mobilize.In addition to the typical metabolic effects of surgery, pain has been demonstrated to increase insulin resistance. In healthy male volunteers | Surgery_Schwartz. Education Office, Montreal, Quebec, Canada.)Brunicardi_Ch50_p2113-p2136.indd 211601/03/19 9:39 AM 2117OPTIMIZING PERIOPERATIVE CARE: ENHANCED RECOVERY AND CHINESE MEDICINECHAPTER 50glucose uptake is reduced. The resulting hyperglycemia can be corrected, however, with the use of exogenous insulin, and when normoglycemia is achieved in the perioperative period, the main components of metabolism also normalize.51The preoperative and postoperative fasting state triggers insulin resistance resulting in a catabolic state with gluconeo-genesis and protein breakdown. Following prolonged fasting states with stress such as following surgery, protein catabolism can be increased several fold over baseline. As less glycogen is stored in the muscle and loss of lean body mass occurs, there is less muscle function and therefore less capacity to mobilize.In addition to the typical metabolic effects of surgery, pain has been demonstrated to increase insulin resistance. In healthy male volunteers | [
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Surgery_Schwartz_13796 | Surgery_Schwartz | muscle function and therefore less capacity to mobilize.In addition to the typical metabolic effects of surgery, pain has been demonstrated to increase insulin resistance. In healthy male volunteers undergoing painful stimulation, glucose uptake was reduced as a direct result of decreased insulin sensitivity.52 In addition, serum cortisol, epinephrine, and free fatty acids were all increased following painful stimulation.Elective surgery results in a state of insulin resistance, with the magnitude of surgery corresponding to a decrease in insulin sensitivity.53 For example, the difference in insulin sen-sitivity following laparoscopic cholecystectomy versus open cholecystectomy is 2.5-fold. More complex abdominal surgery such as an open colorectal resection results in a 3.5-fold increase in insulin resistance over laparoscopic cholecystectomy. As lev-els of insulin resistance increase, complications also increase.54 In addition to an association with complications, insulin resis-tance | Surgery_Schwartz. muscle function and therefore less capacity to mobilize.In addition to the typical metabolic effects of surgery, pain has been demonstrated to increase insulin resistance. In healthy male volunteers undergoing painful stimulation, glucose uptake was reduced as a direct result of decreased insulin sensitivity.52 In addition, serum cortisol, epinephrine, and free fatty acids were all increased following painful stimulation.Elective surgery results in a state of insulin resistance, with the magnitude of surgery corresponding to a decrease in insulin sensitivity.53 For example, the difference in insulin sen-sitivity following laparoscopic cholecystectomy versus open cholecystectomy is 2.5-fold. More complex abdominal surgery such as an open colorectal resection results in a 3.5-fold increase in insulin resistance over laparoscopic cholecystectomy. As lev-els of insulin resistance increase, complications also increase.54 In addition to an association with complications, insulin resis-tance | [
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Surgery_Schwartz_13797 | Surgery_Schwartz | insulin resistance over laparoscopic cholecystectomy. As lev-els of insulin resistance increase, complications also increase.54 In addition to an association with complications, insulin resis-tance has been shown to be an independent predictor of length of stay.53The increased postoperative complications associated with insulin resistance may be not only from the direct meta-bolic effects of insulin on glucose but also from free radical formation. In peripheral tissues that are independent of insulin metabolism, and therefore do not store glycogen, the increased plasma glucose levels result in greater glycolysis and oxygen free radical formation. This leads to alterations in gene expres-sion, which in turn propagates a cycle of increased inflamma-tion causing even more insulin resistance.55 Elective surgery has been implicated in increased inflammatory gene pathways and changes in insulin signaling genes in both adipose and skeletal muscle tissues.56,57Components of an ERP may offset | Surgery_Schwartz. insulin resistance over laparoscopic cholecystectomy. As lev-els of insulin resistance increase, complications also increase.54 In addition to an association with complications, insulin resis-tance has been shown to be an independent predictor of length of stay.53The increased postoperative complications associated with insulin resistance may be not only from the direct meta-bolic effects of insulin on glucose but also from free radical formation. In peripheral tissues that are independent of insulin metabolism, and therefore do not store glycogen, the increased plasma glucose levels result in greater glycolysis and oxygen free radical formation. This leads to alterations in gene expres-sion, which in turn propagates a cycle of increased inflamma-tion causing even more insulin resistance.55 Elective surgery has been implicated in increased inflammatory gene pathways and changes in insulin signaling genes in both adipose and skeletal muscle tissues.56,57Components of an ERP may offset | [
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Surgery_Schwartz_13798 | Surgery_Schwartz | Elective surgery has been implicated in increased inflammatory gene pathways and changes in insulin signaling genes in both adipose and skeletal muscle tissues.56,57Components of an ERP may offset the metabolic and stress responses of surgery. Preoperative carbohydrate supple-mentation has been shown to counter the catabolic effects of the fasted state by stimulating glucose uptake and transition-ing metabolism to a more anabolic state with improved insulin sensitivity.58 Preoperative carbohydrate supplementation also reduces protein loss and improves muscle strength postopera-tively.59-61 When preoperative carbohydrate supplementation is added to epidural analgesia, there is even greater improvement in insulin resistance.62Preoperative Fasting and Preoperative Carbohydrate LoadingTraditionally, patients have been instructed to fast for 6 to 12 hours before surgery to reduce the risk of aspiration of gastric contents during the induction of anesthesia. This fasting state results in a | Surgery_Schwartz. Elective surgery has been implicated in increased inflammatory gene pathways and changes in insulin signaling genes in both adipose and skeletal muscle tissues.56,57Components of an ERP may offset the metabolic and stress responses of surgery. Preoperative carbohydrate supple-mentation has been shown to counter the catabolic effects of the fasted state by stimulating glucose uptake and transition-ing metabolism to a more anabolic state with improved insulin sensitivity.58 Preoperative carbohydrate supplementation also reduces protein loss and improves muscle strength postopera-tively.59-61 When preoperative carbohydrate supplementation is added to epidural analgesia, there is even greater improvement in insulin resistance.62Preoperative Fasting and Preoperative Carbohydrate LoadingTraditionally, patients have been instructed to fast for 6 to 12 hours before surgery to reduce the risk of aspiration of gastric contents during the induction of anesthesia. This fasting state results in a | [
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Surgery_Schwartz_13799 | Surgery_Schwartz | patients have been instructed to fast for 6 to 12 hours before surgery to reduce the risk of aspiration of gastric contents during the induction of anesthesia. This fasting state results in a prolonged period without nutrients or hydration prior to and during surgery, and it can lead to insulin resistance, hyper-glycemia, failure to achieve a postsurgical anabolic state, and sometimes, the need for insulin. Both European and American Societies of Anesthesiology guidelines have supported the use of clear liquid oral intake up to 2 hours prior to surgery with the exception of patients with gastroparesis, intestinal obstruction, or dysphagia.63-65 Carbohydrate oral intake up to 2 hours prior to surgery does not increase aspiration in healthy adults under-going elective surgery and in fact reduces preoperative hunger, thirst, anxiety, and nausea.66,67 In addition, a fasting time of 2 to 4 hours versus more than 4 hours actually results in smaller gastric volume and a higher gastric pH | Surgery_Schwartz. patients have been instructed to fast for 6 to 12 hours before surgery to reduce the risk of aspiration of gastric contents during the induction of anesthesia. This fasting state results in a prolonged period without nutrients or hydration prior to and during surgery, and it can lead to insulin resistance, hyper-glycemia, failure to achieve a postsurgical anabolic state, and sometimes, the need for insulin. Both European and American Societies of Anesthesiology guidelines have supported the use of clear liquid oral intake up to 2 hours prior to surgery with the exception of patients with gastroparesis, intestinal obstruction, or dysphagia.63-65 Carbohydrate oral intake up to 2 hours prior to surgery does not increase aspiration in healthy adults under-going elective surgery and in fact reduces preoperative hunger, thirst, anxiety, and nausea.66,67 In addition, a fasting time of 2 to 4 hours versus more than 4 hours actually results in smaller gastric volume and a higher gastric pH | [
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Surgery_Schwartz_13800 | Surgery_Schwartz | reduces preoperative hunger, thirst, anxiety, and nausea.66,67 In addition, a fasting time of 2 to 4 hours versus more than 4 hours actually results in smaller gastric volume and a higher gastric pH value.68-75 Nevertheless, prior to the introduction of ERAS, the dogma of prolonged nothing-by-mouth status widely adopted many decades ago had little advocacy to change, despite evidence supporting more lib-eral fasting parameters. Current guidelines support fasting from clear liquids for 2 hours and solid food for 6 hours.Preoperative carbohydrate loading prior to surgery in the form of a carbohydrate rich clear liquid improves patient nausea and discomfort over preoperative water hydration or a prolonged fasting state.76 It may also have further benefits over low carbohydrate clear liquid beverages or fasting by changing the overnight fasting state to a fed state and thus altering glu-cose, protein, and fat metabolism by increasing postoperative insulin sensitivity.77-79 Furthermore, in | Surgery_Schwartz. reduces preoperative hunger, thirst, anxiety, and nausea.66,67 In addition, a fasting time of 2 to 4 hours versus more than 4 hours actually results in smaller gastric volume and a higher gastric pH value.68-75 Nevertheless, prior to the introduction of ERAS, the dogma of prolonged nothing-by-mouth status widely adopted many decades ago had little advocacy to change, despite evidence supporting more lib-eral fasting parameters. Current guidelines support fasting from clear liquids for 2 hours and solid food for 6 hours.Preoperative carbohydrate loading prior to surgery in the form of a carbohydrate rich clear liquid improves patient nausea and discomfort over preoperative water hydration or a prolonged fasting state.76 It may also have further benefits over low carbohydrate clear liquid beverages or fasting by changing the overnight fasting state to a fed state and thus altering glu-cose, protein, and fat metabolism by increasing postoperative insulin sensitivity.77-79 Furthermore, in | [
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Surgery_Schwartz_13801 | Surgery_Schwartz | or fasting by changing the overnight fasting state to a fed state and thus altering glu-cose, protein, and fat metabolism by increasing postoperative insulin sensitivity.77-79 Furthermore, in patients whose expected length of stay is greater than 2 days, there is a significant length of stay reduction in patients that receive preoperative carbohy-drate loading.80 The best carbohydrate loading drink is unclear as studies are heterogeneous and the carbohydrate content is variable. Nevertheless, the carbohydrate drink should be hypo-osmolar for faster gastric emptying, result in a fed state with full glycogen stores, and reduce postoperative insulin resis-tance. The most commonly studied carbohydrate loading drink includes 100 g of carbohydrate the evening prior and 50 g of carbohydrate 2 to 3 hours prior to surgery.Intraoperative ConsiderationsSurgical Considerations. Prevention of surgical site infection consists of the use of mechanical, chemical, and/or antimicro-bial modalities. | Surgery_Schwartz. or fasting by changing the overnight fasting state to a fed state and thus altering glu-cose, protein, and fat metabolism by increasing postoperative insulin sensitivity.77-79 Furthermore, in patients whose expected length of stay is greater than 2 days, there is a significant length of stay reduction in patients that receive preoperative carbohy-drate loading.80 The best carbohydrate loading drink is unclear as studies are heterogeneous and the carbohydrate content is variable. Nevertheless, the carbohydrate drink should be hypo-osmolar for faster gastric emptying, result in a fed state with full glycogen stores, and reduce postoperative insulin resis-tance. The most commonly studied carbohydrate loading drink includes 100 g of carbohydrate the evening prior and 50 g of carbohydrate 2 to 3 hours prior to surgery.Intraoperative ConsiderationsSurgical Considerations. Prevention of surgical site infection consists of the use of mechanical, chemical, and/or antimicro-bial modalities. | [
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Subsets and Splits