This literature review, authored by Dr. Reza Lankarani, offers a comprehensive overview of current trends and challenges in modern surgery. It highlights significant issues such as the variable quality of evidence in surgical literature, with a notable lack of high-level evidence, and critical global disparities in access to surgical care, particularly in lower and middle-income countries. The review also examines the burgeoning integration of robotics and AI in surgery, alongside associated adoption barriers, and emphasizes the need for international collaboration to address these complex issues and foster equitable access to advanced surgical practices worldwide.Access inequality in global surgery is a profound challenge, with basic surgical care remaining out of reach for an estimated 5 billion people globally. This situation is likened to a lack of emergency services in remote areas.The sources highlight several critical barriers that contribute to this pervasive access inequality: Unsustainable financing models: Catastrophic expenditures associated with surgical care affect 33 million individuals annually, indicating a severe lack of financial protection. In Low- and Middle-Income Countries (LMICs), only 28% of surgical costs are covered, compared to 89% in high-income countries, where the target for financial protection is 100%. Workforce shortages: LMICs face significant deficits in surgical personnel, with fewer than 5 surgeons per 100,000 people, far below the World Health Organization (WHO) target of 20 surgeons per 100,000. High-income countries, in contrast, have a much higher surgeon density of 56.2 per 100,000. This disparity also correlates with higher postoperative mortality rates in LMICs (5.8%) compared to high-income countries (0.8%), against a WHO target of less than 1%. Infrastructure gaps: Despite the WHO Resolution 76.2 in 2023, surgery remains excluded from 70% of national health plans, which severely limits the development of necessary infrastructure for surgical care.Methodological Tensions and Policy-Practice Misalignment also exacerbate access inequality: The literature reveals a "persistent evidence hierarchy crisis," where high-impact journals are still dominated by retrospective studies, even as global surgery appropriately emphasizes access equity. This means that while the focus is on equity, the research guiding policy may not always be of the highest rigor, with only 1 in 6 surgical studies meeting gold-standard rigor. The Lancet's financing recommendations often overlook the realities of micro-implementation, which contributes to the policy-practice misalignment. The high cost of advanced technologies like the da Vinci 5 surgical robot, at $2 million, remains prohibitive for LMICs, further exacerbating surgical inequities, especially when this amount could fund 100 community surgical clinics.To address these disparities, several policy and practical approaches are being pursued and recommended: National Surgical Plans (NSOAPs): These plans are crucial and necessitate local workforce pipelines, such as Ethiopia's "Saving Lives Through Safe Surgery" (SaLTS) program which trains non-physician surgeons, tiered equipment frameworks (like the WHO's 3-tier surgical device list), and outcome-linked financing. Ethiopia has been a pioneer in this regard, being the first in Africa to establish NSOAPs since 2016. Community-Led Adaptation of Global Models: Mexico's NIHR Global Surgery Unit (GSU) hub in Veracruz focuses on community engagement, adapting models like India's ASHA worker program for rural outreach and translating materials into indigenous languages (e.g., Nahuatl) to overcome linguistic barriers. International Collaboration and South-South Learning: Mexico's adaptation of India's community health model and Ethiopia's NSOAP influencing neighboring African nations (e.g., Zambia, Rwanda) demonstrate effective south-south learning. North-South mentorship, such as the UK's NIHR funding and technical support for GSU hubs, also plays a role in enabling robust research. Language Localization: Mexico and Ethiopia prioritize translating surgical guidelines into indigenous languages (e.g., Oromo, Mixtec) to improve accessibility and overcome linguistic barriers. Policy Recommendations for Policymakers: It is recommended to rebalance innovation portfolios to include scalable solutions (e.g., single-port robotics, AI triage), mandate Level I-II evidence for FDA-cleared surgical devices, adopt "surgical equity impact statements" for new technologies, and expand NIH Study Sections for global surgical health services research. This emphasizes that "The scalpel's future lies not in its sharpness, but in its reach".These efforts aim to bridge the significant gaps in access to surgical care, ensuring that technological advancements and policy frameworks contribute to equitable access rather than widening existing disparities.Evidence gaps in global surgery policy refer to the lack of high-quality, rigorous research and data needed to inform effective decision-making, particularly concerning equitable access, technology adoption, and financial sustainability. These gaps pose a significant challenge to bridging innovation with equity in surgical care.Here's a breakdown of the key evidence gaps identified in the sources: Prevalence of Lower-Quality Evidence: A review of 273 studies from top surgical journals (JAMA Surgery, International Journal of Surgery, British Journal of Surgery) reveals a significant imbalance in evidence quality. 60% (n=164) of publications constitute Level III evidence, meaning they are based on retrospective cohorts. In contrast, only 17.6% (n=48) represent Level I evidence, which includes randomized controlled trials (RCTs), considered the gold standard for clinical research. The average evidence level across these studies is 2.5±0.8, indicating only marginal improvement historically and persistent methodological limitations. Dominance of Case Series in Specific Fields: In pediatric surgery, an analysis of 327 studies on congenital tracheal stenosis (CTS) shows an overwhelming dominance of single-center case series (93.27%). Furthermore, only 4% of this research addressed key innovation areas like biomechanical airway stents or computational fluid dynamics simulations. "Persistent Evidence Hierarchy Crisis": The literature points to a "persistent evidence hierarchy crisis". This means that while global surgery appropriately emphasizes access equity, high-impact journals remain dominated by retrospective studies. This creates a "two-tier evidence ecosystem", where resource-rich settings generate incremental technical advances, but fundamental care gaps persist globally, partly due to the lack of robust clinical trial frameworks for modern surgical innovations (e.g., biodegradable tracheal stents). Lack of Cost-Effectiveness Analyses: A critical evidence gap exists in the absence of cost-effectiveness analyses comparing robotic investments with basic equipment scale-up. This is particularly relevant when considering that the $2 million price tag of a da Vinci 5 surgical robot could alternatively fund 100 community surgical clinics. Without such analyses, it's difficult for policymakers to make informed decisions about resource allocation that truly support equitable access. Impact on Decision-Making: For patients and the public, this translates to a critical issue: only 1 in 6 surgical studies meets gold-standard rigor, meaning many decisions rely on limited data.To address these significant evidence gaps, policymakers are advised to: Mandate Level I-II evidence for FDA-cleared surgical devices. This would ensure that new technologies are rigorously evaluated before widespread adoption. Expand NIH Study Sections for global surgical health services research. This would help generate more high-quality research focused on the unique challenges and needs of global surgical health.These policy changes are essential to ensure that surgical care advancements are based on robust evidence and contribute to equitable access rather than widening existing disparities.Global Surgery Policy is a critical area that addresses access to surgical care, financing, infrastructure, and workforce development globally.Here's a discussion of global surgery policy based on the provided sources:Critical Barriers to Surgical Care AccessA review of "Global Surgery Policy Priorities" identifies three major barriers to accessing surgical care: Unsustainable financing models: Catastrophic expenditures affect 33 million annually. Workforce shortages: Low- and middle-income countries (LMICs) have fewer than 5 surgeons per 100,000 people. Infrastructure gaps: Despite the WHO Resolution 76.2 (2023), surgery remains excluded from 70% of national health plans.Global Surgery Metrics ComparisonThe sources provide a comparison of key indicators: Surgeon Density/100,000: In high-income countries, it's 56.2, while in LMICs, it's 3.8. The WHO target is 20. Postoperative Mortality: High-income countries have 0.8% postoperative mortality, whereas LMICs experience 5.8%. The WHO target is less than 1%. Financial Protection: 89% of surgical costs are covered in high-income countries, compared to only 28% in LMICs. The target is 100%.Methodological Tensions and Policy-Practice MisalignmentThe literature indicates a "persistent evidence hierarchy crisis," where high-impact journals are still dominated by retrospective studies, even as global surgery appropriately emphasizes access equity. Financing Recommendations: The Lancet's financing recommendations often overlook the realities of micro-implementation. National Surgical Plans: These plans necessitate: Local workforce pipelines, such as Ethiopia's SaLTS program, which trains non-physician surgeons. Tiered equipment frameworks, like the WHO's 3-tier surgical device list. Outcome-lin
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Dr. Reza Lankarani, a surgeon and musician, has released a new album showcasing a diverse range of musical styles, from soulful ballads to high-energy tracks. His music, available on iOS and Android platforms, is characterized as a deeply personal exploration, reflecting his unique perspectives as both a medical professional and a dedicated artist.
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