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

Perforated acute appendicitis with no peritonitis in a premature baby: a case report

Abstract Background Acute appendicitis in a neonate and premature baby is still considered a rare entity as diagnosis is always made after surgical exploration for acute abdominal findings mimicking necrotizing enterocolitis. Our reported case is a premature baby who had a perforated appendix with no evidence of peritonitis. Case presentation We describe the case of a premature Bahraini girl born at 29 weeks of gestation by spontaneous vaginal delivery to a 39-year-old G6P5 mother. She was kept on a ventilator for the first 6 days of life, and had an uneventful Neonatal Intensive care stay until her 47th day of life when she developed sepsis that required ventilator support for 3 days. At day 51 she developed abdominal distension and was referred to a pediatric surgeon by day 54 with pneumoperitoneum. Her abdomen was soft with minimal tenderness and no evidence of erythema or edema. In view of pneumoperitoneum and previously reported sepsis, she was taken for exploratory laparotomy. The findings were consistent with a perforated appendix with no evidence of peritonitis or necrotizing enterocolitis. An appendectomy was performed. She had a smooth postoperative recovery. Conclusions Neonatal appendicitis continues to be a diagnostic challenge. Only with a high index of clinical suspicion and teamwork can these cases be managed successfully and mortality and morbidity rates may reduce

Sigmoid volvulus in children: a case report

Abstract Background Sigmoid volvulus is frequently reported in the “volvulus belt” (Middle East, Africa, the Indian subcontinent, Turkey, and South America) and is the third leading cause of large bowel obstruction in North America. It is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group. A high index of suspicion is necessary to diagnose sigmoid volvulus in children. Case presentation We present a 13-year-old Arabian girl who came with features suggestive of intestinal obstruction. Plain abdominal film revealed classic omega (coffee bean) sign of sigmoid volvulus. The volvulus was successfully decompressed by means of a rectal tube in our emergency department. The next day during the same admission the volvulus recurred and was successfully decompressed by endoscopy. She was discharged home on her parents’ request; she presented again 1 month later. This time the volvulus could not be decompressed non-operatively, so she underwent sigmoidectomy with primary anastomosis. Postoperatively she developed paralytic ileus that resolved after 10 days. Following that she did well and was discharged home. She is still free of symptoms 1 year after the resection. Conclusions Sigmoid volvulus is an uncommon problem in children and adolescents, and is rarely considered a diagnosis in this group as a cause of intestinal obstruction. Pediatric surgeons should maintain a high index of suspicion, in order not to miss this important diagnosis, as any delay in instituting treatment has a devastating effect on morbidity as well as mortality. Early diagnosis and prompt treatment confer an excellent prognosis

Button Gastrostomy Tubes for Pediatric Patients: A Tertiary Care Center Experience

Background and Objective. Gastrostomy tube insertion is one of the most common procedures performed as a radical choice to overcome feeding difficulty in children. This study is aimed at describing the replacement of a button tube instead of the long tube for feeding infants and children requiring gastrostomies in a tertiary care hospital. Design and Setting. This retrospective cross-sectional descriptive study was conducted between January 2009 and August 2019 at Salmaniya Medical Complex which is a tertiary health care institute in the Kingdom of Bahrain. Subjects and Methods. Both charts and electronic health records of pediatric patients between the ages of 0 and 14 years were reviewed. Data were collected including age, sex, nationality, diagnosis, surgical information (procedure center and procedure performed), complications, and follow-up. Results. Out of 34 patients who underwent gastrostomy tube insertion, 30 patients had their long tube replaced by a button gastrostomy. Majority were males (N=18, 60%). Prolonged nasogastric tube feeding was the main indication of referral (N=17, 56%) followed by feed intolerance (N=6, 17%) and gastroesophageal reflux disease (N=5, 16%). The main underlying diseases at referral were neurological impairment (N=19, 63%) and metabolic disorders (N=4, 13%). There was no significant difference between patients with neurological disorders and other diseases in terms of gender, nationality, or age. Laparotomy with gastrostomy is the main approach used (N=18, 60%). No reported complications of button tubes in 50% of the patients (N=15). Conclusions. Prolonged nasogastric tube feeding is the main indication of referral for gastrostomy tube insertion. Neurological disorders are the main diagnosis for the cases operated upon. Laparotomy with gastrostomy is the procedure of choice at our center. Majority of patients had no reported complications of button tube replacement. These children are likely to benefit from the button tube with fewer complications

Pancreatic injury in children: a case report and review of the literature

Abstract Background Trauma is the main cause of morbidity and mortality in the pediatric population. Blunt trauma to the abdomen accounts for the majority of abdominal injuries in children. Pancreatic injury, although uncommon (2 to 9%), is the fourth most common solid organ injury. Unlike other solid organ injuries, pancreatic trauma may be subtle and difficult to diagnose. Computed tomography currently is the imaging modality of choice. As the incidence of pancreatic injury in children sustaining blunt abdominal trauma is low, management remains a challenge. Case presentation We present a 7-year-old Bahraini boy who sustained blunt trauma to his abdomen. He presented with abdominal pain and vomiting. His examination revealed abdominal distension and an epigastric bruise. Contrast-enhanced computed tomography reported grade III liver injury, grade I bilateral renal injury, a suspicion of splenic injury, and a grade III to IV pancreatic injury. He was admitted to Pediatric Intensive Care Unit and was treated conservatively. Because he was stable, he was discharged to the surgical ward at day 3. At day 18 he developed a pancreatic pseudocyst that was aspirated and recurred at day 25 when a pigtail catheter was inserted. He was kept on total parenteral nutrition through a peripherally inserted central catheter. The pigtail catheter was removed on day 36 and a low fat diet was started by day 44. He was discharged home at day 55 in good health. Out-patient follow-up and serial abdominal ultrasound showed resolution of the cyst and normalization of blood tests. Conclusion Non-operative management of pancreatic injury is effective and safe in hemodynamically stable patients with no other indication for surgery

Impact of the COVID-19 pandemic on patients with paediatric cancer in low-income, middle-income and high-income countries: a multicentre, international, observational cohort study

OBJECTIVES: Paediatric cancer is a leading cause of death for children. Children in low-income and middle-income countries (LMICs) were four times more likely to die than children in high-income countries (HICs). This study aimed to test the hypothesis that the COVID-19 pandemic had affected the delivery of healthcare services worldwide, and exacerbated the disparity in paediatric cancer outcomes between LMICs and HICs. DESIGN: A multicentre, international, collaborative cohort study. SETTING: 91 hospitals and cancer centres in 39 countries providing cancer treatment to paediatric patients between March and December 2020. PARTICIPANTS: Patients were included if they were under the age of 18 years, and newly diagnosed with or undergoing active cancer treatment for Acute lymphoblastic leukaemia, non-Hodgkin's lymphoma, Hodgkin lymphoma, Wilms' tumour, sarcoma, retinoblastoma, gliomas, medulloblastomas or neuroblastomas, in keeping with the WHO Global Initiative for Childhood Cancer. MAIN OUTCOME MEASURE: All-cause mortality at 30 days and 90 days. RESULTS: 1660 patients were recruited. 219 children had changes to their treatment due to the pandemic. Patients in LMICs were primarily affected (n=182/219, 83.1%). Relative to patients with paediatric cancer in HICs, patients with paediatric cancer in LMICs had 12.1 (95% CI 2.93 to 50.3) and 7.9 (95% CI 3.2 to 19.7) times the odds of death at 30 days and 90 days, respectively, after presentation during the COVID-19 pandemic (p<0.001). After adjusting for confounders, patients with paediatric cancer in LMICs had 15.6 (95% CI 3.7 to 65.8) times the odds of death at 30 days (p<0.001). CONCLUSIONS: The COVID-19 pandemic has affected paediatric oncology service provision. It has disproportionately affected patients in LMICs, highlighting and compounding existing disparities in healthcare systems globally that need addressing urgently. However, many patients with paediatric cancer continued to receive their normal standard of care. This speaks to the adaptability and resilience of healthcare systems and healthcare workers globally

Twelve-month observational study of children with cancer in 41 countries during the COVID-19 pandemic

Childhood cancer is a leading cause of death. It is unclear whether the COVID-19 pandemic has impacted childhood cancer mortality. In this study, we aimed to establish all-cause mortality rates for childhood cancers during the COVID-19 pandemic and determine the factors associated with mortality