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

Aggressive behaviour of solid-pseudopapillary tumor of the pancreas in adults: A case report and review of the literature

Solid-pseudopapillary tumor (SPT) is a rare neoplasm of the pancreas that usually occurs in young females. It is generally considered a low-grade malignant tumor that can remain asymptomatic for several years. The occurrence of infiltrating varieties of SPT is around 10%-15%. Between 1986 and 2006, 282 cystic tumors of the pancreas were observed. Among them a SPT was diagnosed in 8 patients (2.8%) with only one infiltrating variety. This was diagnosed in a 49-year-old female 13 years after the sonographic evidence of a small pancreatic cystic lesion interpreted as a pseudocyst. The tumor invaded a long segment of the portal-mesenteric vein confluence, and was removed with a total pancreatectomy, resection of the portal vein and reconstruction with the internal jugular vein. Histological examination confirmed the R-0 resection of the primary SPT, although a vascular invasion was demonstrated. The postoperative course was uneventful, but 32 mo after surgery the patient experienced diffuse liver metastases. Chemotherapy with different drugs was started. The patient is alive and symptom-free, with stable disease, 75 mo after surgery. Twenty-five patients with invasion of the portal vein and/or of mesenteric vessels were retrieved from the literature, 16 recent patients with tumor relapse after potentially curative resection were also retrieved. The best treatment remains a radical resection whenever possible, even in locally advanced or metastatic disease. The role of chemotherapy, and/or radiotherapy, is still to be defined

Pancreaticoduodenectomy with unusual artery reconstruction in a patient with celiac axis occlusion: report of a case

Abstract Celiac axis stenosis is a relatively common finding that may require major revascularization during pancreaticoduodenectomy. We present a patient that underwent pancreaticoduodenectomy for intraductal papillary mucinous neoplasm of the pancreatic head associated with celiac axis obstruction. To secure arterial blood flow to the upper abdominal organs, the superior posterior pancreaticoduodenal artery and the posterior-inferior pancreatic-duodenal artery were carefully preserved, and anastomosed. The postoperative course was complicated by a pseudoaneurysm of the splenic artery that was successfully treated with angiographic embolization through the vascular bypass. This may be a valid alternative procedure for revascularization of the common hepatic artery during pancreaticoduodenectomy in a patient with celiac axis stenosis

Morbidity of Left Pancreatectomy when Associated with Multivisceral Resection for Abdominal Mesenchymal Neoplasms

Context Resection of adjacent visceral organs is often required in surgery for abdominal mesenchymal tumors. Objectives To analyze the specific perioperative morbidity and mortality of a left pancreatectomy in multivisceral resections for mesenchymal tumors. Patients This paper considered all patients treated at National Cancer Institute, Milan, Italy, from January 1997 to May 2009 for the resection of abdominal mesenchymal neoplasms requiring a concomitant left pancreatectomy. The extension of surgery, pathology of both the tumor and the pancreatic tissue, completeness of resection, administration of pre or postoperative treatments and postoperative outcome were analyzed. The overall survival of the entire population was also assessed. Results Fifty-seven patients affected by localized left retroperitoneal mesenchymal neoplasms or intra-abdominal gastrointestinal stromal tumors were identified. A macroscopically complete resection was achieved in all but 3 patients (5.3%) and the neoplastic involvement of pancreatic tissue was documented at pathology in 26 (45.6%) patients. Surgical postoperative complications occurred in 20 patients (35.1%); 7 patients (12.3%) developed a postoperative pancreatic fistula. With a median follow-up of the surviving patients of 32 months (interquartile range: 20-57 months), the overall survival at 5 years was 67.0%. Conclusion Left pancreatic resection seemed to be a safe procedure, even when it is part of a multivisceral resection for abdominal mesenchymal neoplasms. When margins are crucial for cure, the left pancreas should then always be resected, independently of its direct infiltration.Image: Kaplan-Meier estimates of overall survival for the entire series

Uncommon Case of a Post-Traumatic Portal Vein Pseudoaneurysm Treated with Percutaneous Transhepatic Stent Grafting

We describe a man who presented with a traumatic portal vein pseudoaneurysm, which was subsequently managed with a percutaneous transhepatic stent graft. This case demonstrates a rarely seen condition in the traumatic population and a novel management strategy, which should be considered in the management of this challenging injury