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

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

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

Endovascular Treatment with Primary Stenting of Acutely Thrombosed Popliteal Artery Aneurysms

Only anecdotal cases concerning primary stenting of thrombosed popliteal artery aneurysm (PAA) without a preoperative intra-arterial thrombolysis are reported. We report our series of 6 patients treated with this technique

Fungal keratitis due to Scopulariopsis brevicaulis in an eye previously suffering from herpetic keratitis.

In the case reported, herpes virus I after having caused relapsing keratitis in an eye promoted the formation of a severe corneal ulcer caused by Scopulariopsis brevicaulis, a saprophytic mycete found in soil, which only once has been described as the cause of keratitis in man. Scopulariopsis was identified microscopically after culturing the conjunctival secretion on Sabouraud dextrose agar medium, while DNA probe tests confirmed the absence of herpes virus I. Topical and oral administration of miconazole and scraping of the corneal infiltrate dispersed the infection. Subsequently local steroids were given to reduce the neovascularization, and a therapeutic contact lens was applied because of intercurrent corneal thinning. Three months after beginning antifungal therapy, the visual acuity had increased from 1/120 to 1/10. The case described confirms that S. brevicaulis can cause opportunist infections in a cornea previously damaged by a different agent

Staged in situ aorto-iliac hybrid technique: an original technique to treat complex juxtarenal and iliac aneurysms

Background: To report a novel staged hybrid technique to treat complex juxtarenal abdominal aortic aneurysm (JAAA) associated with at least one iliac artery aneurysm (IA) with no adequate distal fixation zone. Methods: The novel technique herein described has two main “staged” steps. The first step consists in creating an adequate distal fixation zone by endovascular means; after hypogastric embolization an iliac stent-graft has placed from 5 mm above the aortic bifurcation to the external iliac artery. The second step is the surgical resection of the JAAA and graft placement sutured distally to the stent-graft which was always performed the day after. Results: The five cases included (mean age 74 years), were rejected for fenestrated or branched endovascular aortic repair or iliac branch devices. Four tube grafts and one aorto-bi-iliac graft were sutured to one stent-graft (N.=3), two stent-grafts in iliac kissing configuration (N.=1) and to a main body of a bifurcated stent-graft (N.=1). Mean follow-up duration was 14 (4-27) months with no mortality. Technical success was obtained in all cases (2 suprarenal clamping). Postoperative complications included two pleural effusions, two transient gluteal intermittent claudications, and one renal failure. Conclusions: The technique herein described seems to be a feasible and cost-effective alternative treatment for selected concomitant complex JAAAs and IAs unsuitable for totally endovascular treatment

A Matched Case-Control Study on Open and Endovascular Treatment of Popliteal Artery Aneurysms

To compare early and late results of open and endovascular management of popliteal artery aneurysm in a retrospective single-center matched case-control study Methods: From 1981 to 2015, 309 consecutive interventions for popliteal artery aneurysm were performed in our institution, in 59 cases with endovascular repair and in 250 cases with open repair. Endovascular repair was preferred in older asymptomatic patients, while open repair was offered more frequently to patients with a thrombosed popliteal artery aneurysm and a poor run-off status. A one-to-one coarsened exact matching on the basis of the baseline demographic, clinical, and anatomical covariates significantly different between the two treatment options was performed and two equivalent groups of 56 endovascular repairs and open repairs were generated. The two groups were compared in terms of perioperative results with χ2test and of follow-up outcomes with the Kaplan-Meier curves and log-rank test

Prevention of type II endoleaks: results of a study including 1000 patients

Aim: The incidence for type II endoleaks (T2E) reported in literature varies between 10% and 20% but their natural history is still unclear. The aim of this study was to retrospectively evaluate our single centre experience of approximately 1000 patients treated with endovascular aneurysm repair (EVAR) to determine the role of T2Es in mid and long term failure and to optimize their management. Methods: Baseline characteristics, operative and follow-up data of consecutive patients undergoing EVAR at our Institution were prospectively collected in a dedicated database. Patients with a demonstrated type II endoleak at the followup were divided in two groups depending on the spontaneous regression of the endoleak. We compared baseline characteristics, mortality, relation to aneurysm sac evolution, association with type I or III endoleaks and reintervention. The incidence of recurrent T2Es (defined as newly onset endoleaks after a surgical, trans-lumbar or trans-arterial treatment) was also evaluated to define a proper management of these complications. Results: From March 1999 to May 2014, 943 consecutive patients with an aortic or aorto-iliac aneurysms were treated with EVAR. During the follow-up 260 patients had a T2E. Out of these 260 patients, 99 had a spontaneous regression of the endoleak (38.1%) and were defined as Group 1 while 161 had a persistent-T2E (61.9%) and were defined as Group 2. The mean regression time of T2Es was 26.8 months (±21.8) with a median value of 18 months (12-36). During follow-up, an aneurysm sac enlargement >5 mm was found in 10 patients (10.4%) in Group 1 compared with 37 (25.2%) in Group 2 (P<0.001) with a consequent increase in the rate of reinterventions (18.2% vs. 30.4%) for the second group (P<0.001). Adjusted analysis showed an increase risk of persistent-T2Es for age over 80 years (OR, 1.5: CI, 1.0-2.2; P=0.028), hypertension (OR, 1.5: CI, 1.0-2.3; P=0.043), ASA HI and TV (OR, 1.8: CI, 1.3-2.5; P<0.001) and presence of T2E at the completion angiography (OR, 1.5: CI, 1-2.2; P=0.031). Kaplan-Meier curves showed a significant decrease in the overall survival rate for patients presenting a persistent T2E (P=0.041). Conclusion: Persistent T2Es are related with higher mortality, sac enlargement and reinterventions rates. As their treatment appears to be often unsuccessful, the identification of subclasses of patients at risk may alter the treatment option

Ozonized autohaemotransfusion could be a potential rapid-acting antidepressant medication in elderly patients

Abstract Objective - To determine if, in aged subjects suffering from a mild to moderate depression and mild cognitive impairment (MCI), ozonized autohaemotransfusion exerts rapid and sustained antidepressant effects and positively influenced the cognitive impairment. Methods - Sixteen aged subjects were autohaemotransfused twice (once with ozonized, the other with nonozonized blood) at four day interval. Before ( t0 ) and 30 minutes( t1 ) and 48 hours ( t2 ) after the end of autohaemotransfusions, serum levels of brain-derived neurotrophic factor (BDNF) were measured and rating tests for both depression and memory capacity were performed. Twelve of the sixteen participants received a long-term treatment of ozonized autohaemotransfusion over six weeks at the rythm of two autohaemotransfusion per week ; serum level of BDNF and rating tests for depression and memory abilities were measured in these subjects 14 days after the last ozonized autohaemotransfusion. Results - A single ozonized autohaemotransfusion induced a rapid (within minutes) antidepressant effect in elderly patients with mild to moderate depression and mild cognitive impairment; this effect remained significant for, at least, 48 hours The long-term treatment confirmed the antidepressant effect of ozonization and also demonstrated a significant increase of serum levels of BDNF. Conclusion – The findings suggest that ozonized autohaemotransfusion is a new antidepressant agent capable of enhancing BDNF levels and, above all, with a very rapid onset of the antidepressant effect and quite free of adverse effects

Results of the multicenter pELVIS Registry for isolated common iliac aneurysms treated by the iliac branch device

Objective: We evaluated the short- and long-term results of off-label use of iliac branch devices (IBDs) in isolated common iliac artery aneurysms compared with the manufacturer-recommended configuration with additional extension in the infrarenal aorta based on the pELVIS Registry (pErformance of iLiac branch deVIces for aneurysmS involving the iliac bifurcation). Methods: Between January 2005 and April 2017, 804 patients underwent endovascular aneurysm repair with 910 IBDs owing to aneurysmal involvement of the iliac bifurcation in nine high-volume European vascular centers. Among this cohort, 231 IBDs were implanted in 207 patients to treat an isolated common iliac aneurysm; 91 IBDs (group 1) were implanted without proximal aortic extension in the infrarenal aorta, and in the remaining cases (n = 140; group 2) an aortic bifurcated stent graft was deployed proximally as stated in the instructions for use. Primary outcomes were IBD and target hypogastric artery occlusions, type I and III endoleaks, procedure-related reinterventions, and aneurysm-related deaths. Results: Technical success was achieved in 90 cases (98.9%) in group 1 versus 137 cases (97.8%) in group 2 (P =.55). The overall aneurysm-related early reintervention rate for the two groups was 4.4% (4 of 91) and 2.1% (3 of 140), respectively (P =.33). The 30-day mortality was 1.1% in group 1 (n = 1), and 0% in group 2 (P =.21). The median postoperative follow-up in groups 1 and 2 were 34.1 months (range, 1-108 months) and 17.5 months (range, 1-90 months), respectively. The estimated rates of freedom from IBD occlusion at 60 months were 86% in group 1 and 83% in group 2 (P =.69). The estimated rates of freedom from target hypogastric artery occlusion at 60 months were 98.3% in group 1 and 91.3% in group 2 (P =.45). The estimated freedom from reintervention rates at 60 months for types I, types III, and IBD stenosis-occlusion were 78.2% in group 1 and 79.9% in group 2 (P =.79). The estimated freedom from all cause reintervention at 60 months was 64.5% in group 1 and 66.1% in group 2 (P =.44). The estimated freedom from aneurysm-related death at 60 months was 97.9% in group 1 and 100% in group 2 (P =.83). Conclusions: Single IBD placement for isolated common iliac artery aneurysms seems to be a safe and effective treatment option, when a proper anatomic patient selection is provided. Major benefits are represented by the decrease in X ray exposure, overall procedural time, and use of contrast medium, without affecting perioperative and long-term results in comparison with more extensive procedures