Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Pancreatic fistulas after pancreatico-duodenectomies: are pancreatico-gastrostomies safer than pancreatico-jejunostomies? a quasi-experiment and propensity-score adjusted analysis

BACKGROUND Pancreatic fistula (PF) is a major contributor to morbidity and mortality after pancreaticoduodenectomy (PD). There remains a debate as to whether reestablishing pancreaticoenteric continuity through a Pancreatico-Gastrostomy (PG,) compared to a Pancreatico-Jejunostomy(PJ,) can decrease the risk of PF and total complications. GOAL: We compared the outcomes of patients undergoing PG or PJ after PD at the McGill University Health Centers, where patient assignment to PG or PJ fulfills most of the criteria for a Quasi-Experiment. METHODS Data on pre-operative factors and post- operative complications was collected for patients undergoing PD in our database between 1999 and 2011 and receiving either a PG or PJ reconstruction. We performed a propensity-score adjusted logistic regression to identify the effect of surgical technique on outcomes of PF, delayed gastric emptying (DGE), and total complications. We used the ISGPF and Strasberg and Linehan definition and classification for PF and the ISGPS definition for DGE. The total morbidity experience was assessed using the Clavien-Dindo classification and the Comprehensive Comorbidity Index (CCI) for all complications. RESULTS 23/103 and 20/103 (p=0.49) of patients had PF and 74/103 and 55/103 patients had all-grades DGE in the PG and PJ groups respectively (p=0.02). The groups did not differ with regards to Clavien-Dindo grade of complications (p=0.29) but did differ with regards to the CCI (38.4 vs. 31.4 for PG vs. PG respectively, p=0.02.) Propensity-score adjusted multivariate analysis showed no effect of surgical technique on PF (p=0.89), DGE grades B/C (p=0.9) or CCI (p=0.41) but there remained an effect on all-grades DGE (p=0.012.) CONCLUSION Patients undergoing PG reconstruction did not have less PF than those reconstructed with PJ after PD at our institution; Though Patients in both groups experienced a similar burden of complications, the odds of all- grade DGE were higher in the PG group.CONTEXTE les fistules pacreatiques (PF) constituent une cause significative de la morbiditée et mortalité subie par les patients qui recoivent une pancreaticoduodenectomie (PD). La technique ideale pour retablir la continuité pancreatico-enterique est inconnue. Il n'est pas donné que les Pancreatico-Gastrostomies (PG) donne moi de PF et de complications post-operatives que les Pancreatico-Jejunostomies(PJ). BUT: Nous avons comparé le profile de complications post-operatoire chez les patients ayant subi une PG or PJ apres PD au Centre Universitaire de Sante McGill. METHODOLOGIE: Nous avons collecté des données pre-operatoires ainsi que les complications post- operatoires pour les patients ayant subi une PD dans notre base de données entre 1999 et 2011 et ayant subi une reconstruction par PG ou PJ. Nous avons performé une regression logistique ajustée pour un" propensity-score" pour identifier l'effet de la technique chirurgicale sur les PF, les delais de la motilitée gastrique (DGE), et les complications totales. nous avons utilisé les classifications ISGPF et Strasberg et Linehan pour PF et la definition ISGPS pour DGE. La morbidité totale a été evaluée par la classification Clavien-Dindo et l'Index Comprehensif de Morbidité (CCI). RESULTATS 23/103 et 20/103 (p=0.49) des patients ont developpé une PF et 74/103 et 55/103 patients ont eu DGE en periode post operatoire dans les groupes PG et PJ respectivement (p=0.02). Le grade Clavien-Dindo des complications n'etait pas different entre les groupes (p=0.29) mais le CCI l'etait (38.4 vs. 31.4 for PG vs. PG respectivement, p=0.02.) l'analyse multivariable ajustée pour le "Propensity-score" n'a pas montré d'effet de la technique chirurgical sur PF (p=0.89), DGE grades B/C (p=0.9) ou CCI (p=0.41) mais il restait un effet sur le DGE de toutes les grades de severité (p=0.012.) CONCLUSION Les patients ayant recu une PG n'avaient pas moins de PF que ceux ayant recu une PJ aprés PD a notre institution; Les deux groupes ont souffert du meme profile de complications, mais le groupe PG avait plus de DGE de toutes grades

Exploring human factors in the operating room: a protocol for a scoping review of training offerings for healthcare professionals

Introduction Applying human factors principles in surgical care has potential benefits for patient safety and care delivery. Although different theoretical frameworks of human factors exist, how providers are being trained in human factors and how human factors are being understood in vivo in the operating room (OR) remain unknown. The aim of this scoping review is to evaluate the application of human factors for the OR environment as described by education and training offerings for healthcare professionals.Methods and analysis This scoping review will follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines. MEDLINE, Embase, PsycINFO, CINAHL, Health and Psychosocial Instruments and ERIC databases were searched on August 2020 from inception to identify relevant studies that describe the content, application and impact of human factors training for healthcare professionals or trainees who work in or interface with the OR environment. Titles, abstracts and full texts will be independently screened by two authors for eligible studies. Any disagreements will be resolved by discussion or by a third author when disagreement persists. Study information and training characteristics, such as the training tool used and type of learners and teachers, will be charted and summarised, and key themes in human factors training will be identified. Each training offering will be classified under the appropriate knowledge area(s) of human factors described by the Chartered Institute of Ergonomics & Human Factors (CIEHF). Themes that are not captured by the CIEHF framework will be independently recorded by two authors and included based on group discussion and consensus.Ethics and dissemination Research ethics board approval is not required for this scoping review. The findings of this study will be disseminated at local and national conferences and will be published in a peer-reviewed journal

Unresectable pancreatic adenocarcinoma: do we know who survives?

AbstractBackgroundThis study attempts to define clinical predictors of survival in patients with unresectable pancreatic adenocarcinoma (UPA).MethodsA retrospective study of 94 consecutive patients diagnosed with UPA from 2001 to 2006 was performed. Using data for these patients, a symptom score was devised through a forward stepwise Cox proportional hazards model based on four weighted criteria: weight loss of >10% of body weight; pain; jaundice, and smoking. The symptom score was subsequently validated in a distinct cohort of 32 patients diagnosed with UPA in 2007.ResultsIn the original cohort, the overall median survival was 9.0 months (95% confidence interval [CI] 7.6–10.4). This altered to 10.3 months (95% CI 6.1–14.5) in patients with locally advanced disease, and 6.6 months (95% CI 4.2–9.0) in patients with distant metastasis. Median survival was 14.6 months (95% CI 13.1–16.1) in patients with a low symptom (LS) score and 6.3 months (95% CI 4.1–8.5) in patients with a high symptom (HS) score. A total of 73% of LS score patients survived beyond 9 months, compared with only 38% of HS score patients (P<0.001). The discrimination of the LS score was greater than that of any conventional method, including imaging. The validation cohort confirmed the discriminative ability of the symptom score for survival.ConclusionsA simple and clinically meaningful point-based symptom score can successfully predict survival in patients with UPA

McGill Brisbane symptom score for patients with resectable pancreatic head adenocarcinoma

AIM: To evaluate the ability of the McGill Brisbane Symptom Score (MBSS) to predict survival in resectable pancreatic head adenocarcinoma (PHA) patients. METHODS: All PHA patients (n = 83) undergoing pancreaticoduodenectomy at the McGill University Health Center, Quebec between 1/2001-1/2010 were evaluated. Data related to patient and cancer characteristics, MBSS variables, and treatment were collected; univariable and multivariable survival analyses were performed. We obtained complete follow-up until February 2011 in all patients through the database of the provincial health insurance plan of Quebec. The unique health insurance numbers of these patients were used to retrieve information from this database which captures all billable clinical encounters, and ensures 100% actual survival data. RESULTS: Median survival was 23 mo overall: 45 mo for patients with low MBSS, 17 mo for high MBSS (P = 0.005). At twelve months survival was 83.3% (95%CI: 66.6-92.1) vs 58.1% (95%CI: 42.1-71.2) in those with low vs high MBSS, and24 mo survival was 63.8% (95%CI: 45.9-77.1) and 34.0% (95%CI: 20.2-48.2) respectively. In the multivariate Cox model (stratified by chemotherapy), after addition of clinically meaningful covariates, MBSS was the variable with the strongest association with survival (HR = 2.63; P = 0.001). Adjuvant chemotherapy interacted with MBSS category such that only high MBSS patients accrued a benefit. In univariate analysis we found a lower mortality in high MBSS but not low MBSS patients receiving adjuvant chemotherapy. This interaction variable, on Cox model, resulted in an adjusted mortality HR for the high MBSS (compared to low MBSS) of 4.14 (95%CI: 1.48-11.64) without chemotherapy and 2.11 (95%CI: 1.06-4.17) with chemotherapy. CONCLUSION: The MBSS is a simple prognostic tool for resectable PHA. Preoperative categorization of patients according to the MBSS allows effective stratification of patients to guide therapy

Phlebotomy resulting in controlled hypovolemia to prevent blood loss in major hepatic resections (PRICE-2) : study protocol for a phase 3 randomized controlled trial

Introduction: Blood loss and red blood cell (RBC) transfusion in liver surgery are areas of concern for surgeons, anesthesiologists, and patients alike. While various methods are employed to reduce surgical blood loss, the evidence base surrounding each intervention is limited. Hypovolemic phlebotomy, the removal of whole blood from the patient without volume replacement during liver transection, has been strongly associated with decreased bleeding and RBC transfusion in observational studies. This trial aims to investigate whether hypovolemic phlebotomy is superior to usual care in reducing RBC transfusions in liver resection. Methods: This study is a double-blind multicenter randomized controlled trial. Adult patients undergoing major hepatic resections for any indication will be randomly allocated in a 1:1 ratio to either hypovolemic phlebotomy and usual care or usual care alone. Exclusion criteria will be minor resections, preoperative hemoglobin <100g/L, renal insufficiency, and other contraindication to hypovolemic phlebotomy. The primary outcome will be the proportion of patients receiving at least one allogeneic RBC transfusion unit within 30 days of the onset of surgery. Secondary outcomes will include transfusion of other allogeneic blood products, blood loss, morbidity, mortality, and intraoperative physiologic parameters. The surgical team will be blinded to the intervention. Randomization will occur on the morning of surgery. The sample size will comprise 440 patients. Enrolment will occur at four Canadian academic liver surgery centers over a 4-year period. Ethics approval will be obtained at participating sites before enrolment. Discussion: The results of this randomized control trial will provide high-quality evidence regarding the use of hypovolemic phlebotomy in major liver resection and its effects on RBC transfusion. If proven to be effective, this intervention could become standard of care in liver operations internationally and become incorporated within perioperative patient blood management programs.Medicine, Faculty ofNon UBCAnesthesiology, Pharmacology and Therapeutics, Department ofSurgery, Department ofReviewedFacultyResearcherPostdoctoralOthe