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

Abstract P2-02-02: A review of the accuracy of wire localisation using digital breast tomosynthesis (DBT) in a prospective series of 81 patients

Abstract Introduction: Digital breast tomosynthesis allows identification of impalpable lesions in three-dimensions. We have devised a technique for wire placement using a gridded plate that allows localisation of such lesions for subsequent surgical excision. Method: 81 consecutive cases were studied prospectively between Jan 2012 and May 2014. The localisation is usually performed by the operating surgeon under local anaesthetic shortly before the patient is transferred to the operating theatres. Our surgeons consider the optimal position for the tip of the wire to be 1 cm beyond and 1cm to the side of the lesion placed using only the CC or lateral projection. The patient is positioned with the aperture of a gridded plate over the lesion needing to be surgically removed. A single DBT is acquired and the volumes reviewed. The lesion is identified and the depth in the breast recorded (Z coordinate). The ideal position for the wire is then marked in that plane and the volume scrolled through to bring the calibrated plate into focus. This identifies the X and Y coordinates, which are then recorded. The wire is then placed freehand in the line of the beam and a further DBT performed to check the position of the wire without needing to reposition the patient. A specimen x-ray is performed immediately following excision to confirm the target lesion is included. The results are verified at the subsequent multidisciplinary team (MDT) meeting. Results: Once the target is identified, the average time for the localisation procedure and check DBT was 4 minutes. This series included both diagnostic (N=24, 30%) and therapeutic excisions (N=57, 70%). Patients presented both from screening (N=64, 79%) and symptomatically (N=17, 21%). The age range of the patients was 42-79y (mean 59y). 54 (67%) cases were undergoing excision for calcifications, 15 (19%) for impalpable masses, 11 (13%) for radial scars or distortions and 1 for glandular asymmetry. The final diagnoses following excision were IDC 34 (42%), DCIS 29 (36%), benign 13 (16%) and 1 case each of ILC, spindle cell tumour, mucinous carcinoma, phyllodes and pleomorphic LCIS. In all cases the target lesion was shown to be present in the specimen x-ray, confirmed on histology and ratified by the MDT. Conclusions: Wire localisation using DBT is a quick and accurate method of localising impalpable lesions for surgical excision. Citation Format: Simon DH Holt, Khaldoun MY Nadi, Amrita Gurung, Helen R Williams, Anita M Huws, Yousef M Sharaiha. A review of the accuracy of wire localisation using digital breast tomosynthesis (DBT) in a prospective series of 81 patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-02-02.</jats:p

Abstract P3-01-01: Can synthetic 2D mammography be used to select patients in whom there is no need to review the digital breast tomosynthesis from which they were constructed? A review of 1871 consecutive mammogram sets of patients presenting symptomatically or for follow

Abstract Introduction: A synthetic 2D mammogram can be created by combining the individual optimally enhanced 1mm slices of a digital breast tomosynthesis (DBT). Theoretically this could help overcome the problems associated with standard 2D mammograms (superimposition of structures hiding small cancers) and the significantly increased reading time and decreased conspicuity of microcalcifications associated with DBT. It may avoid the need for the double x-ray exposure required for combination 2D and DBT currently being suggested to maximise the specificity and sensitivity of mammography. The hypothesis we wished to test is, "if the synthetic 2D is normal, is there any advantage to looking at the DBTs as well?" Method: We have reviewed 1000 consecutive cases presenting symptomatically or to our follow up clinic all of which underwent DBT on a Hologic Dimensions machine. From the 3D data sets synthetic 2D mammograms were constructed (Hologic C-view technology). One breast radiologist with 12 years experience of interpreting mammograms and more recently 4 years experience in interpreting DBTs was asked to first review the 2D synthetic mammograms (each breast CC and MLO) and report them before then reviewing the DBTs and issuing a final report. The mammograms were reported M1 to M5 using the standard BIRADs criteria. The BIRADs scores for each breast were recorded prospectively and entered into a database. BIRADS Classification - Synthetic 2D v DBT  Synthetic 2D   M1M2M3M4M5 M16104000DBTM27109610210 M3013484 M4004210 M5002247Table 1 Results: 1000 consecutive patients were studied between October 2013 and March 2014. The average age of the women was 58.1 years (range 29 to 92). Of these some were under follow up after mastectomy so in total there were 1871 individual mammogram sets reported. Table 1 summarises the correlation between C-view and DBT reporting. The correlation between the two modalities is very close, but importantly there was only one patient in whom the C-view was reported normal or benign (M1 or M2) but the DBT reported a possible abnormality (M3). However, 31 cases reported as suspicious or malignant M3, 4 or 5 by C-view were subsequently downgraded to benign after review of the DBT. Conclusion: In a symptomatic and follow up clinic, our study suggests that much radiologist’s time and x-ray exposure to the patient could be saved by using synthetic 2D mammograms derived from the DBT data rather than using separate 2D studies. Only if the C-view is reported M3, 4 or 5 is it necessary to review the DBT but for all these patients the DBT is already available without further x-ray exposure or recall. Citation Format: Simon DH Holt, Ali Moalla, Helen R Williams, Khaldoun MY Nadi, Anita M Huws, Amrita Gurung, Daniel Thomas, Yousef M Sharaiha. Can synthetic 2D mammography be used to select patients in whom there is no need to review the digital breast tomosynthesis from which they were constructed? A review of 1871 consecutive mammogram sets of patients presenting symptomatically or for follow [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P3-01-01.</jats:p

Three wound-dressing strategies to reduce surgical site infection after abdominal surgery: the Bluebelle feasibility study and pilot RCT.

BACKGROUND Surgical site infection (SSI) affects up to 20% of people with a primary closed wound after surgery. Wound dressings may reduce SSI. OBJECTIVE To assess the feasibility of a multicentre randomised controlled trial (RCT) to evaluate the effectiveness and cost-effectiveness of dressing types or no dressing to reduce SSI in primary surgical wounds. DESIGN Phase A - semistructured interviews, outcome measure development, practice survey, literature reviews and value-of-information analysis. Phase B - pilot RCT with qualitative research and questionnaire validation. Patients and the public were involved. SETTING Usual NHS care. PARTICIPANTS Patients undergoing elective/non-elective abdominal surgery, including caesarean section. INTERVENTIONS Phase A - none. Phase B - simple dressing, glue-as-a-dressing (tissue adhesive) or 'no dressing'. MAIN OUTCOME MEASURES Phase A - pilot RCT design; SSI, patient experience and wound management questionnaires; dressing practices; and value-of-information of a RCT. Phase B - participants screened, proportions consented/randomised; acceptability of interventions; adherence; retention; validity and reliability of SSI measure; and cost drivers. DATA SOURCES Phase A - interviews with patients and health-care professionals (HCPs), narrative data from published RCTs and data about dressing practices. Phase B - participants and HCPs in five hospitals. RESULTS Phase A - we interviewed 102 participants. HCPs interpreted 'dressing' variably and reported using available products. HCPs suggested practical/clinical reasons for dressing use, acknowledged the weak evidence base and felt that a RCT including a 'no dressing' group was acceptable. A survey showed that 68% of 1769 wounds (727 participants) had simple dressings and 27% had glue-as-a-dressing. Dressings were used similarly in elective and non-elective surgery. The SSI questionnaire was developed from a content analysis of existing SSI tools and interviews, yielding 19 domains and 16 items. A main RCT would be valuable to the NHS at a willingness to pay of £20,000 per quality-adjusted life-year. Phase B - from 4 March 2016 to 30 November 2016, we approached 862 patients for the pilot RCT; 81.1% were eligible, 59.4% consented and 394 were randomised (simple,  = 133; glue,  = 129; no dressing,  = 132); non-adherence was 3 out of 133, 8 out of 129 and 20 out of 132, respectively. SSI occurred in 51 out of 281 participants. We interviewed 55 participants. All dressing strategies were acceptable to stakeholders, with no indication that adherence was problematic. Adherence aids and patients' understanding of their allocated dressing appeared to be key. The SSI questionnaire response rate overall was 67.2%. Items in the SSI questionnaire fitted a single scale, which had good reliability (test-retest and Cronbach's alpha of > 0.7) and diagnostic accuracy (-statistic = 0.906). The key cost drivers were hospital appointments, dressings and redressings, use of new medicines and primary care appointments. LIMITATIONS Multiple activities, often in parallel, were challenging to co-ordinate. An amendment took 4 months, restricting recruitment to the pilot RCT. Only 67% of participants completed the SSI questionnaire. We could not implement photography in theatres. CONCLUSIONS A main RCT of dressing strategies is feasible and would be valuable to the NHS. The SSI questionnaire is sufficiently accurate to be used as the primary outcome. A main trial with three groups (as in the pilot) would be valuable to the NHS, using a primary outcome of SSI at discharge and patient-reported SSI symptoms at 4-8 weeks. TRIAL REGISTRATION Phase A - Current Controlled Trials ISRCTN06792113; Phase B - Current Controlled Trials ISRCTN49328913. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 23, No. 39. See the NIHR Journals Library website for further project information. Funding was also provided by the Medical Research Council ConDuCT-II Hub (reference number MR/K025643/1)