Glucagon-like peptide-1 (GLP-1) receptor agonists have emerged as a cornerstone therapy for obesity management, yet long-term comparative effectiveness across diabetes status, adherence, and specific agents remains unclear. This study evaluates multi-year weight-loss outcomes associated with GLP-1 therapy and characterizes medication- and phenotype-specific differences. This study represents a subgroup analysis of a large-scale meta-analysis including clinical trials, observational and case–control studies published from 2010 to 2025 reporting long-term weight outcomes for GLP-1 agents. Outcomes were evaluated across mixed, intention-to-treat (ITT), and treatment-adherent populations and stratified by diabetes status. Mixed-effects meta-regression was performed to evaluate independent predictors of weight loss. A total of 56,580 patients from 45 studies were included. GLP-1 therapy consistently produced greater weight loss than placebo across all populations. Non-diabetic participants achieved the greatest reductions, losing 15.7

Introduction Obesity has been linked to increased mortality and respiratory complications following trauma. However, the association between obesity and respiratory complications in trauma patients undergoing emergent surgery remains unclear. Given the altered respiratory mechanics and airway management difficulties in obese patients, we hypothesized that obesity would be associated with increased respiratory complications and mortality in trauma patients requiring emergent surgery. Methods The Trauma-Quality-Improvement-Program database (2017-2022) was queried for trauma patients ≥18-y-old undergoing emergency surgery. Emergency surgery was defined as undergoing an operation within 2 h of arrival. Patients were categorized as obese (BMI ≥30) or non-obese (BMI <30). The primary outcome was respiratory complications, defined as unplanned intubation, ventilator-associated pneumonia, and/or acute respiratory distress syndrome. Bivariate and multivariable logistic regression analyses were performed. Results From 240,120 patients, 75,386 (31.4%) were obese. Obese patients had a lower rate of lung injuries (17.0% versus 18.8%, P < 0.001) but higher rates of respiratory complications (3.9% versus 2.7%, P < 0.001) and mortality (4.2% versus 3.6%, P < 0.001). After adjusting for covariates, the associated risk of respiratory complications (OR 1.43, CI 1.36-1.51, P < 0.001) and mortality (OR 1.11, CI 1.05-1.17, P < 0.001) were higher for obese patients. Conclusions Despite lower rates of lung injuries, obese patients had an increased associated risk of respiratory complications and mortality. Obesity is linked to physiological changes, such as impaired airway management and ventilation, which increase the risk of respiratory issues. These findings highlight the need to include obesity in risk prediction models for trauma patients requiring emergent surgery.

BACKGROUND:When selecting surgical residents, programs emphasize quantifiable data from the Electronic Residency Application Service application. However, it is unclear whether Electronic Residency Application Service data are associated with future resident performance or any of the qualities (surgical judgment, leadership, and medical knowledge) that our group has identified as being predictive of graduate performance. Our objective was to determine whether residency application variables are associated with subsequent residency graduate performance as rated by surgical educators. METHODS:Faculty from 12 general surgery residency programs rated graduates from 2017 to 2020 on 4 outcomes: overall performance, surgical judgment, leadership, and medical knowledge. Graduates' Electronic Residency Application Service data were collected, including medical school type, United States Medical Examination scores, honors society memberships, extracurriculars, clerkship honors, and class rank. Data were analyzed using the Spearman rank-order correlation. Least absolute shrinkage and selection operator regression was performed to select a model predictive of each outcome from preresidency variables. RESULTS:A total of 258 graduates were evaluated. Regarding overall residency graduate performance rating, there were weak associations with the United States Medical Examination step 2 score (r = 0.23, P < .01); honors in family medicine (r = 0.17, P = .02), obstetrics/gynecology (r = 0.17, P = .01), pediatrics (r = 0.15, P = .02), and surgery (r = 0.14, P = .03); proportion of clerkship honors (r = 0.2, P < .01); and class rank (r = 0.18, P = .03). None of the preresidency variables were selected for a predictive model via least absolute shrinkage and selection operator regression for any of the 4 outcomes measured. CONCLUSION:There is a weak correlation between measurable residency application data and subsequent resident performance as rated by surgical educators. On least absolute shrinkage and selection operator regression, no residency application variables were predictive of graduate performance. These findings question the value of measurable application data in resident selection and highlight the importance of cultivating outstanding surgeons throughout training.

Introduction Operative independence of surgical residents has decreased over time with implications on resident education and preparedness for practice. This study assessed the association between trainee autonomy and perioperative complications and morbidity and mortality in breast surgery. Methods The 2005-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients undergoing breast surgery. Cases were stratified by trainee involvement: attending primary (AP), resident supervised (RS), and resident primary (RP). Outcomes included wound complication, length of stay (LOS), major complication, and 30-day mortality. Bivariate and multivariable logistic regressions were performed to identify predictors of major complications. Results Of 149,936 patients who underwent breast surgery, 67,548 (45.1%) were AP, 81,684 (54.5%) were RS, and 704 (0.47%) were RP. RP cases were older and had higher American Society of Anesthesiologists (ASA) class. More axillary lymphadenectomy was performed as RP cases (AP 40.1% versus RS 45.5% versus RP 49.0%, P < 0.001). Operative time increased with resident autonomy (AP 50 versus RS 73 versus RP 80 min, P < 0.001), while LOS decreased (AP 4.4% versus RS 7.2% versus RP 4.3%, P < 0.001). RP cases had the lowest rate of wound complications (AP 2.1% versus RS 2.3% versus RP 2.0%, P = 0.02). There were no differences in major complication or mortality. Resident autonomy was not an independent predictor of major complications. Conclusions While the relationship between trainee operative autonomy and oncologic outcomes remains unclear, autonomy of residents in breast surgery is associated with low rates of complications and mortality. Despite higher involvement with high-risk patients and axillary lymphadenectomy, trainee autonomy in breast surgery is not associated with increased morbidity or mortality.

BACKGROUND:Radiographically occult peritoneal carcinomatosis (PC) is a major concern in gastric cancer; hence staging laparoscopy (SL) is recommended prior to initiating treatment, particularly neoadjuvant systemic therapy (NST). However, compliance may vary and could result in understaging. We sought to evaluate the utilization of SL in patients with gastric cancer referred to academic institutions. PATIENTS AND METHODS:This is a multi-institution retrospective study of patients with a diagnosis of gastric/gastroesophageal junction (GEJ) Siewert 3 adenocarcinoma who received treatment between 2010 and 2022. Demographics, tumor characteristics, treatment, and recurrence data were collected. Descriptive statistics and multivariate analysis were performed. RESULTS:A total of 280 patients with gastric/GEJ cancer were identified, of which 75 (26.8%) had clinical stage IV disease and were excluded. Of the remaining 205 patients, 74 (36.1%) underwent upfront surgery and 131 (63.1%) underwent NST. Only 39 (29.8%) patients in the NST group underwent SL, of whom 15(38.4%) were found to have peritoneal metastases; 12 (80%) had gross PC and 3 (20%) had positive cytology. Among patients who underwent surgical resection after NST (n = 77), 26 (33.7%) experienced disease recurrence with a median time to recurrence of 11.6 months. The peritoneum (n = 10/26, 38.5%) was the most common site of recurrence. CONCLUSIONS:Compliance with SL prior to NST is poor (29.8%), and in the group that underwent SL, 38% of patients were upstaged due to presence of peritoneal metastases. These findings are significant, as the management and prognosis of peritoneal metastases are drastically different. Various factors could lead to poor compliance with SL, hence better compliance and alternate approaches to reliably detect PC are needed.

Due to pandemic-related restrictions, medical schools transitioned to virtual clinical rotations in 2020. Virtual learning is now an integral part of medical education, but there remain questions as to whether it adequately prepares students for the rigors of surgical residency. We hypothesized that students exposed to virtual learning during medical school demonstrate inferior performance during residency as compared to their predecessors. Data were collected from 12 General Surgery Residency programs. Residents who began training in academic years (AY) 2018–2022 were included and followed for 2 years. Residents who started in AY2018–2020 (conventional group) prior to the introduction of virtual rotations were compared to residents who started in AY2021–2022 (virtual group) after virtual clinical rotations were implemented during medical school. The primary outcome was the sum of annual milestone scores, adjusted for post-graduate year, and analyzed with a linear mixed-effects model. Secondary outcomes included milestone scores by ACGME competency category, USMLE scores, ABSITE percent correct, remediation, and attrition. 334 residents were included: 199 in the conventional group and 135 in the virtual group. There was no difference in mean USMLE score between conventional vs virtual groups: USMLE Step1: 239 vs 240, p = 0.52, USMLE Step2: 251 vs 251, p = 0.77. When adjusted for post-graduate year (PGY), virtual learning was associated with an average decrease of 2.3 points over the sum of all milestones over the course of a year of residency when compared to the conventional group (95

BACKGROUND:Esophageal stents are effective in managing various pathologies. However, they are limited by their most common complication: migration. This study aimed to present the largest comprehensive review of the risk factors associated with stent migration and the interventions leveraged to prevent stent migration. METHODS:A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were primary data sources (no systematic reviews), ≥18 years of age, esophageal stent placement, and reported indication for intervention, site of placement, and migration rate. A total of 162 studies met the inclusion criteria. Proportions experiencing migration were pooled using a random-effects model with a DerSimonian-Laird estimator to account for potential heterogeneity, and forest plots were used to visualize the treatment effects across studies. RESULTS:A total of 14,092 patients were included in the analysis. The mean migration rate across all studies and stent types was 17.2%, and the mean reintervention rate was 83.2%. Cancerous indications, benign strictures, history of esophageal surgery, stent diameter of <20 mm, plastic stents, and fully covered stents were associated with significantly higher migration rates. There was a trend toward stents using antimigration technology having lower migration rates (effect size [ES] = 0.15; 95% CI, 0.10-0.20) than those that did not (ES = 0.33; 95% CI, 0.18-0.48). However, this difference was not significant. There were no statistically significant differences among the stent fixation strategies (clips, sutures, wire hooks, and Shim technique). CONCLUSION:Several risk factors are associated with stent migration. However, no currently available solutions can significantly reduce stent migration. Further optimization of these devices or the creation of new technology to prevent migration is required.

OBJECTIVE To highlight the evolution of surgical morbidity and mortality conferences (MMCs) from the early 20th century as a means of identifying surgeon error into current practices as identifying hospital-based system factors that contribute to adverse patient events. Further, to elucidate differences in the perception of MMCs between trainees and attending surgeons as well as differences in the structure of MMCs geographically and by institution type. DESIGN We developed a survey that was distributed to current American College of Surgeon members through Survey Monkey. SETTING Survey-based study. PARTICIPANTS Current members of the American College of Surgeons, including Board of Governors, surgeons, and trainees. RESULTS There were a total of 1,396 responses to the survey, 814 (58%) from surgical trainees and 582 (42%) from attending surgeons. Both surgical trainees and attending surgeons noted that the most common day for MMCs was Wednesday and that the most common time for MMCs was before 7:30 AM. Further, most surgical trainees and attending surgeons noted that there was no structured format to their institution's MMCs and that increased attending surgeon engagement would make MMCs more educational. Significant variations in MMCs existed across both geographic region and by institution type. CONCLUSION The results from this survey highlight key aspects of MMCs that contribute to their educational value. Staff engagement was noted to be the most educational aspect of MMCs. While geographic and institutional differences will likely persist, efforts should be made to increase staff engagement at MMCs in addition to a more structured approach.

Importance It is uncertain whether current measures of achievement during medical school predict exceptional performance during surgical residency. One surrogate of excellence during residency may be awards, especially those given for teaching and annual overall accomplishment. Objective Determine whether markers of superior performance during medical school documented in the Electronic Residency Application Service (ERAS) application and student record correlated with receiving awards during residency. Design Data was analyzed from ERAS and student applications of 296 residency graduates. Spearman correlation coefficients were calculated. Participants 296 residency graduates from 14 US general surgery residency programs. Main Outcomes and Measurements The relationship between each residency and preresidency variable and the outcome of receiving any qualifying award. Secondary analysis included the correlation with winning a teaching or annual overall award. Results Although 140 (48%) residents received an award during residency, only 69 (23.3%) received a teaching award, while 50 (17.6%) received one for annual overall performance. Membership in Alpha Omega Alpha (AOA) and honors in pediatrics rotation correlated with receiving any award. USMLE step 1 score and AOA membership reached statistically significant positively correlation with receiving a teaching award, while completing a sub-internship at that institution was negatively associated. For annual overall awards, only completing a sub-internship at the same institution reached statistical significance. Conclusions None of the traditional metrics in the ERAS or global student record consistently correlated with receiving an award during residency. Our findings suggest that preresidency factors available on the global application, including grades, test scores, and honor society membership, poorly correlate with exceptional general surgery residency performance as measured by receiving awards. Residency programs should shift away from using traditional ERAS metrics as the primary criteria for selection, but rather as 1 component of holistic applicant review.

OBJECTIVE: To determine whether participation in certain hobbies (e.g., participation in sports, playing musical instruments, or other hobbies requiring fine motor skills), preresidency, are associated with higher technical skills ratings at the time of residency graduation. DESIGN: Faculty members from 14 general surgery residency programs scored individual graduates from 2017 to 2020 on their technical skills using a 5 -point Likert scale. Hobbies for these residents were collected from their Electronic Residency Application Service (ERAS) data. A single reviewer classified each ERAS hobby into predefined categories including musical instruments, sports requiring hand -eye coordination, team sports, and activities necessitating hand -eye coordination. Spearman correlation coefficients were calculated for the relationship between each category of hobby-as well as the total number of hobbies in each category-and the outcome of surgical faculty ratings of residents' technical surgical skills during their last year of residency. A proportional odds model including the above predictive variables was also fit to the data. SETTING: Fourteen general surgery residency programs. PARTICIPANTS: General surgery residency graduates from 14 different programs from 2017 to 2020. RESULTS: There were 296 residents across 14 institutions. The average ranking of residents' technical skills was 3.24 (SD 1.1). A total of 40% of residents played sports involving hand -eye coordination, 31% played team sports, 28% participated in nonsport hobbies that require eye -hand coordination, and 20% played musical instruments. Correlation coefficients were not statistically significant for any of the categories. In the proportional odds model, none of the variables were associated with statistically significant increased odds of a higher technical skills rating. CONCLUSIONS: There was no correlation between general surgery chief residents' technical skills as rated by faculty, and self-reported pre-residency hobbies on the ERAS application. These findings suggest such hobbies prior to residency are unlikely to predict future technical skills prowess. (J Surg Ed 81:339-343. (c) 2023 Published by Elsevier Inc. on behalf of Association of Program Directors in Surgery.)

Background: Previous reports identified an association between obese adolescents (OAs) and lower extremity (LE) fractures after blunt trauma. However, the type of LE fracture remains unclear. We hypothesized that OAs presenting after motor vehicle collision (MVC) have a higher risk of severe LE fracture and will require a longer length of stay (LOS) and more support services upon discharge, compared to non-OAs. Methods: The 2017-2019 Trauma Quality Improvement Program database was queried for adolescents (12-17- years-old) presenting after MVC. The primary outcome was LE fracture. A severe fracture was defined by abbreviated injury scale >= 3. OAs were defined by a body mass index (BMI) >= 30. Results: From 22,610 MVCs, 3325 (14.7 %) included OAs. The rate of any LE fracture was higher for OAs (21.6 % vs. 18.8 %, p < 0.001). On subset analysis the only LE fracture at higher risk in OAs was a femur fracture (13 % vs. 9.1 %, p < 0.001). After adjusting for sex and age, the risk for severe LE fracture (OR 1.34, CI 1.18-1.53, p < 0.001) was higher for OAs. OAs with a femur fracture had a longer median LOS (5 vs. 4 days, p = 0.003) and were more likely discharged with additional support services including home-health or inpatient rehabilitation (30.6 % vs. 21.4 %, p < 0.001). Conclusion: OAs sustaining MVCs have increased associated risk of femur fractures. OAs are more likely to have a higher-grade LE injury, experience a longer LOS, and require additional support services upon discharge. Future research is needed to determine if early disposition planning with social work assistance can help shorten LOS.

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Our careers as surgeons are some of the busiest and perhaps most sought after in existence. We have all put in countless years of tenacious effort, at times blood, frequent sweat, and occasional tears, to have the privilege to care for others and correct their ailments. Many of us are like freight trains rolling down the tracks indefinitely. But all too often we finish our training and head down those tracks without considering what stops we should make along the way, which forks in the tracks we should consider taking, and perhaps most often, we do not consider how we are going to eventually stop the train. Most of us have been witness to colleagues who keep working beyond their prime, be it for lack of alternative opportunities, lack of hobbies to retire to, or for lack of insight into their own decline. From these observations was born this presidential panel. As you can see, it is a collection of past presidents of So Cal ACS, with the exception for Dr Freischlag (who we all know would have served as president at some point had she never relocated away from Southern California). Each of these speakers has unique experience from their own careers that they will share with us so we can take pause and consider their insights and wisdom for how to navigate a successful and satisfying career.

An increasing body of literature supports the clinical benefit of nutritional assessment and optimization in surgical patients; however, this data has yet to be consolidated in a practical fashion for use by surgeons. In this narrative review, we concisely aggregate emerging data to highlight the role of nutritional optimization as a promising, practical perioperative intervention to reduce complications and improve outcomes in surgical patients. This review of the surgical nutrition literature was conducted via large database review. There were no distinct inclusion/exclusion criteria for this review; however, we focused on adult populations using up-to-date literature from high-quality systematic reviews or randomized controlled trials when available. Current perioperative management focuses on the mitigation of intraoperative and immediate postoperative complications. Well-defined risk calculators attempt to stratify patient surgical risk preoperatively to reduce adverse events directly related to surgical procedures, such as hemorrhage, cardiopulmonary compromise, or infection. However, there is a lack of standardization of prognostic tools, nutritional protocols, and guidelines governing the assessment, composition, and administration of nutritional supplementation. Substantial data exist demonstrating the clinical benefit in the operative setting. In this work, we provide a fundamental primer for surgeons to understand the clinical importance of nutritional optimization along with practical prognostic tools and recommendations for use in their practice. While the extent to which nutritional optimization improves patient outcomes is debatable, the evidence clearly demonstrates a clinically meaningful benefit. Evaluating nutritional status differs based on disease severity and etiology of presentation, thus surgeons must select the appropriate prognostic tools to assess their patients during the perioperative period. This information will catalyze subsequent work with a multidisciplinary team to provide personalized dietary plans for patients and spark research to establish protocols for specific presentations.