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

Nationwide prospective audit for the evaluation of appendicitis risk prediction models in adults: Right iliac fossa treatment (RIFT) - Turkey

Background: Appendicitis is the most prevalent surgical emergency. The negative appendicectomy rate and diagnostic uncertainty are important concerns. This study aimed to assess the effectiveness of current appendicitis risk prediction models in patients with acute right iliac fossa pain. Methods: A nationwide prospective observational study was conducted, including all consecutive adult patients who presented with right iliac fossa pain. Diagnostic, clinical and negative appendicectomy rate data were recorded. The Alvarado score, Appendicitis Inflammatory Response (AIR), Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Adult Appendicitis Score systems were calculated with collected data to classify patients into risk categories. Diagnostic value and categorization performance were evaluated, with use of risk category-based metrics including 'true positive rate' (percentage of appendicitis patients in the highest risk category), 'failure rate' (percentage of patients with appendicitis in the lowest risk category) and 'categorization resolution' (true positive rate/failure rate). Results: A total of 3358 patients from 84 centres were included. Female patients were less likely to undergo surgery than men (71.5% versus 82.5% respectively; relative risk 0.866, 95% c.i. 0.834 to 0.901, P 0.001); with a three-fold higher negative appendicectomy rate (11.3% versus 4.1% respectively; relative risk 2.744, 95% c.i. 2.047 to 3.677, P 0.001). Ultrasonography was utilized in 56.8% and computed tomography in 75.2% of all patients. The Adult Appendicitis Score had the best diagnostic performance for the whole population; however, only RIPASA was significant in men. All scoring systems were successful in females patients, but Adult Appendicitis Score had the highest area under the receiver operating characteristic curve value. The RIPASA and the Adult Appendicitis Score had the best categorization resolution values, complemented by their exceedingly low failure rates in both male and female patients. Alvarado and AIR had extremely high failure rates in men. Conclusion: The negative appendicectomy rate was low overall, but women had an almost three-fold higher negative appendicectomy rate despite lower likelihood to undergo surgery. The overuse of imaging tests, best exemplified by the 75.2% frequency of patients undergoing computed tomography, may lead to increased costs. Risk-scoring systems such as RIPASA and Adult Appendicitis Score appear to be superior to Alvarado and AIR. © 2024 The Author(s). Published by Oxford University Press on behalf of BJS Foundation Ltd.Tibbi Akademi

Head-down tilt lithotomy position and well-leg compartment syndrome: An international survey of current practice

Aim: Well-leg compartment syndrome (WLCS) is a serious complication of prolonged surgery in the head-down tilt lithotomy (HDTL) position associated with increased postoperative morbidity and mortality. However, there is a lack of awareness and clinical guidance regarding prevention of WLCS. The aim of this study was to assess current HDTL-related practices and occurrence of WLCS among a global cohort of clinicians. Method: An international online survey of clinicians was conducted between July and December 2023. Data analysis involved descriptive statistics, machine learning techniques and qualitative content analysis. Results: A total of 595 clinicians from 71 countries and 14 specialities participated. Most (98%) reported routine use of HDTL, 27% of whom did not implement any preventive strategies. ‘Leg rest’ was the most reported preventive measure (41%), commonly initiated after 2 or 3 h of HDTL (79%), for 10–15 min (56%). Overall, 170 cases of WLCS were reported by 21% of respondents. The majority reported unilateral WLCS (81%) following a laparoscopic procedure (63%) performed in HDTL (64%). Only 28% of respondents discussed WLCS during consent for operations in HDTL. Machine learning identified ‘duration of uninterrupted HDTL’ as a positive predictor of the occurrence of WLCS (p < 0.001). Content analysis demonstrated that clinician perspectives and practices regarding WLCS are significantly influenced by personal experience, mostly due to a poor evidence base and lack of standardized institutional policies. Conclusion: Perioperative practices during procedures in HDTL vary substantially, and are primarily informed by clinician experience and preferences. There is a need for evidence-based consensus on best practices to enhance safety during procedures in HDTL