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

Duodenal Ampulla Neuroendocrine Tumor with GISTs of the Proximal Jejunum: A Case Report

Neuroendocrine tumors (NEN) are a type of heterogenous, slow-growing tumors, that only in about half of the cases can be found in the gastrointestinal tract. Half of these is in the small intestine. The ampullary NENs are rare, accounting for less than 1% of gastroenteropancreatic NENs. Gastrointestinal stromal tumors (GIST) are a more common type of tumors of the gastrointestinal tract that consist of pacemaker cells. The occurrence of both tumors simultaneously is rare, but in patients with neurofibromatosis type 1, the co-existence of NEN and GIST is more often. Here we report a case of simultaneous occurrence of a well-differentiated NEN and a GIST in a patient without neurofibromatosis. Also, we provide a short review of the current knowledge and treatment strategies regarding these tumors

Duodenal Ampulla Neuroendocrine Tumor with GISTs of the Proximal Jejunum: A Case Report

Neuroendocrine tumors (NEN) are a type of heterogenous, slow-growing tumors, that only in about half of the cases can be found in the gastrointestinal tract. Half of these is in the small intestine. The ampullary NENs are rare, accounting for less than 1% of gastroenteropancreatic NENs. Gastrointestinal stromal tumors (GIST) are a more common type of tumors of the gastrointestinal tract that consist of pacemaker cells. The occurrence of both tumors simultaneously is rare, but in patients with neurofibromatosis type 1, the co-existence of NEN and GIST is more often. Here we report a case of simultaneous occurrence of a well-differentiated NEN and a GIST in a patient without neurofibromatosis. Also, we provide a short review of the current knowledge and treatment strategies regarding these tumors

Which Are the Best Site and Stand Conditions for Silver Fir (<i>Abies alba</i> Mill.) Located in the Carpathian Mountains?

Silver fir (Abies alba Mill.) is one of the most valuable and productive tree species across European mountains, that accomplish multiple economic, protective and ecologic functions. Alongside spruce (Picea abies (L.) Karst) and beech (Fagus sylvatica L.), silver fir is a characteristic species for the Romanian Carpathians. Although silver fir tree is recommended for the diversification of forests in order to increase the resistance to climate change, it is very sensitive to climatic excesses, especially those that proceed rapidly. Therefore, the aim of this study is to investigate both the environmental conditions and stand characteristics of fir from five mountain ranges of the Romanian Carpathians. The study is based on data recorded over a period of 10 years (1990–2000). As such, a total of 77,251 stands that occupy 211,954 hectares have been investigated in regard to silver fir behaviour. MATLAB scripts were used for analysing consistent data volumes as well as the impact of eight factors on the silver fir productivity (altitude, field aspect, field slope, soil type, participation percentage, road distance, structure and consistency). Our analysis has revealed that higher silver fir productivity is found at altitudes of up to 1200 m, on mid and upper slopes, on NW field aspects, on eutric cambisols and dystric cambisols, with a 10–20% participation in stand composition and in relatively-even aged stands with a full consistency. This study offers valuable insights for forest managers that require comprehensive information in adopting effective strategies to enhance forest resilience under climate change

Which Are the Best Site and Stand Conditions for Silver Fir (Abies alba Mill.) Located in the Carpathian Mountains?

Silver fir (Abies alba Mill.) is one of the most valuable and productive tree species across European mountains, that accomplish multiple economic, protective and ecologic functions. Alongside spruce (Picea abies (L.) Karst) and beech (Fagus sylvatica L.), silver fir is a characteristic species for the Romanian Carpathians. Although silver fir tree is recommended for the diversification of forests in order to increase the resistance to climate change, it is very sensitive to climatic excesses, especially those that proceed rapidly. Therefore, the aim of this study is to investigate both the environmental conditions and stand characteristics of fir from five mountain ranges of the Romanian Carpathians. The study is based on data recorded over a period of 10 years (1990–2000). As such, a total of 77,251 stands that occupy 211,954 hectares have been investigated in regard to silver fir behaviour. MATLAB scripts were used for analysing consistent data volumes as well as the impact of eight factors on the silver fir productivity (altitude, field aspect, field slope, soil type, participation percentage, road distance, structure and consistency). Our analysis has revealed that higher silver fir productivity is found at altitudes of up to 1200 m, on mid and upper slopes, on NW field aspects, on eutric cambisols and dystric cambisols, with a 10–20% participation in stand composition and in relatively-even aged stands with a full consistency. This study offers valuable insights for forest managers that require comprehensive information in adopting effective strategies to enhance forest resilience under climate change.</jats:p

Biological and Histological Assessment of the Hepatoportoenterostomy Role in Biliary Atresia as a Stand-Alone Procedure or as a Bridge toward Liver Transplantation

Background and objectives: In patients with biliary atresia (BA), hepatoportoenterostomy (HPE) is still a valuable therapeutic tool for prolonged survival or a safer transition to liver transplantation. The main focus today is towards efficient screening programs, a faster diagnostic, and prompt treatment. However, the limited information on BA pathophysiology makes valuable any experience in disease management. This study aimed to analyze the evolution and survival of patients with BA referred for HPE (Kasai operation) in our department. Materials and Methods: A retrospective analysis was performed on fourteen patients with BA, diagnosed in the pediatric department and further referred for HPE in our surgical department between 2010 and 2016. After HPE, the need for transplantation was assessed according to patients cytomegalovirus (CMV) status, and histological and biochemical analysis. Follow-up results at 1&ndash;4 years and long term survival were assessed. Results: Mean age at surgery was 70 days. Surgery in patients younger than 60 days was correlated with survival. Jaundice&rsquo;s clearance rate at three months was 36%. Total and direct bilirubin values had a significant variation between patients with liver transplants and native liver (p = 0.02). CMV was positive in eight patients, half with transplant need and half with native liver survival. Smooth muscle actin (SMA) positivity was proof of advanced fibrosis. The overall survival rate was 79%, with 75% for native liver patients and an 83% survival rate for those with liver transplantation. Transplantation was performed in six patients (43%), with a mean of 10 months between HPE and transplantation. Transplanted patients had better survival. Complications were diagnosed in 63% of patients. The mean follow-up period was six years. Conclusions: HPE, even performed in advanced cirrhosis, allows a significant survival, and ensures an essential time gain for patients requiring liver transplantation. A younger age at surgery is correlated with a better outcome, despite early CMV infection