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Academic global surgery consists of collaborative partnerships that address surgical inequities through research, training, education, advocacy, and diplomacy. It has been characterized by increased scholastic production through global surgery publications, dedicated global surgery sessions within scientific conferences, global surgery-specific research grants, database development to support global surgery research, global surgery research fellowships, and global surgery-based academic promotion paradigms. The increased emphasis on global surgery research has been accompanied by multiple ethical challenges. This article reviews critical ethical dilemmas presented by global surgery research efforts and proposes interventions on the partnership, infrastructural, and policy levels to enhance fidelity within research partnerships., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Global surgery is a medical field dedicated to the facilitation of timely access to safe, affordable, and high-quality surgical healthcare worldwide, including support for necessary surgery and anesthesia infrastructure. Standard surgical training in the US does not provide necessary exposure to the range of surgical operations and nontechnical skills critical to practice in resource-limited contexts. Therefore, academic medical institutions have sought to bridge this training gap by establishing global surgery-focused rotations, fellowships, and integrated global surgery residencies. However, the presence of trainees pursuing education for careers in resource-variable settings presents an added layer of ethical complexity that must be carefully considered on the individual, programmatic, and institutional level. This article reviews the complexities relevant to global surgery trainees across these levels and offers potential mechanisms for addressing these ethical challenges., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Public reporting of cardiac surgery ratings has been advocated to inform patient selection of hospitals. Although Society of Thoracic Surgeons (STS) ratings are based on audited risk-adjusted patient outcomes, other rating systems rely on administrative databases. In this study, we evaluate correlation among 4 widely used hospital rating systems for coronary artery bypass grafting (CABG) and aortic valve replacement (AVR)., Study Design: We identified an initial cohort of 602 hospitals from US News & World Report's (USN) listing of the 2016-2017 "Best Hospitals for Cardiology & Heart Surgery." From this cohort, current publicly available CABG and AVR ratings were collected from the STS, USN, Centers for Medicare & Medicaid Services, and Healthgrades. All 4 rating systems rated hospitals as high, average, or below average performers for each procedure. We then determined the match rate between rating systems for individual hospitals and assessed interrater reliability with Cohen's κ., Results: Rating systems had different distributions of high and low performing ratings assigned. USN rated hospitals as high performing for both CABG and AVR more frequently compared with STS, Healthgrades, and Centers for Medicare & Medicaid Services. For CABG, the match rate between systems varied from 50% to 85%, with the best match between STS and Centers for Medicare & Medicaid Services. Similarly for AVR, the match rate varied from 50% to 73%, with the best match between STS and Healthgrades. Interrater reliability was poor among the 4 rating systems (κ < 0.2) and consistent with no agreement for CABG and AVR ratings., Conclusions: Publicly reported cardiac surgery ratings have significant discrepancy and poor correlation. This might confuse instead of clarify public perception of hospital quality for cardiac surgery., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Readmission within 30 days of adult cardiac surgery procedures is a frequent contributor to the costs of cardiac surgery hospitalizations, but current data regarding risk factors for readmission are limited. We therefore sought to analyze quality improvement risk factors for readmissions after coronary bypass surgery (CABG)., Study Design: The records of patients undergoing CABG at our institution from July 2006 to June 2011 were evaluated for variables with potential literature-based associations with readmission, including New York Cardiac Surgery Reporting System (CSRS) risk factors, discharge medications, and laboratory values., Results: The readmission rate was 13% (n = 158 of 1,205); the CSRS predicted rate was 8.7% (observed/expected ratio = 1.5). Median time from CABG discharge to readmission was 6 days (interquartile range [IQ] 3 to 13 days). Median readmission length of stay was 4 days (IQ 2 to 7 days). The most frequent reasons for readmission were cardiac (n = 40 [25% of readmissions]) and pulmonary complications, including pleural effusions (n = 36 [23%]). Beyond CSRS risk factors, only abnormal discharge serum creatinine was associated with increased readmission (p = 0.05). Combining CSRS risk variables for government insurance and unplanned reoperation led to the highest readmission risk (odds ratio [OR] 5.7, 95% CI 1.7 to 18.7)., Conclusions: Coronary bypass surgery readmissions remain a persistent clinical challenge. Given that readmissions often occur within the first week postdischarge and are typically of short duration, post-CABG readmissions may be reduced through careful postoperative surveillance for readmission risk factors (eg, abnormal serum creatinine or unplanned reoperations) and/or for frequent causes of readmission (eg, pleural effusions)., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Blood transfusion persists as an important risk of open heart operations despite the recent introduction of a variety of new pharmacologic agents and blood conservation techniques as independent therapies. A comprehensive multimodality blood conservation program was developed to minimize this risk., Study Design: To provide a strategy for operating without transfusion, this program was prospectively applied to 50 adult patients who are Jehovah's Witnesses and have undergone open heart operation at our institution since 1992. The blood conservation program used for these patients included the use of high-dose erythropoietin (800 U/kg load, 500 U/kg every other day), aprotinin (6 million U total dose full Hammersmith regimen), "maximal" volume intraoperative autologous blood donation, intraoperative cell salvage, continuous shed blood reinfusion, and drawing as few blood specimens as possible., Results: Procedures performed included first-time coronary bypass operations (n = 30) and more complex operations, including reoperations, valve replacements, and multiple valve replacements with or without coronary bypass (n = 20). Despite the absence of transfusion, the mean discharge hematocrit in these patients was greater than 30 percent, and there was no anemia-related mortality rate in this group. The overall in-hospital mortality for the group was 4 percent. A subset analysis was performed between the 30 first-time coronary bypass patients (group 1) and a control group of 30 consecutive patients who were not Jehovah's Witnesses but had undergone first-time coronary bypass during the same period (group 2). The blood conservation program described in the previous paragraph was not used in group 2 patients and specific transfusion criteria were prospectively applied. The chest tube output in group 1 patients was less than 40 percent of that for group 2 patients at all points measured after operation (p < 0.01). Postoperative hematocrit levels in group 1 were greater than those for group 2, despite the absence of red blood cell transfusion and despite a significantly lower admission hematocrit and red blood cell mass in group 1. The average length of stay and ancillary costs for the two groups were equivalent. Although group 1 and 2 patients were well matched for preoperative transfusion risk factors, none of the group 1 patients required transfusion, but 17 (57 percent) group 2 patients met transfusion criteria and received 3.0 +/- 4.8 U (mean plus or minus standard deviation) of homologous blood or blood products., Conclusions: These results suggest that even complex open heart operations can be performed without homologous transfusion by optimally applying available blood conservation techniques. More generalized application of these measures may increasingly allow "bloodless" operations in all patients.