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

Evaluation of the impact of endometriotic lesions on patient's pelvic pain symptoms

Purpose: To verify if different endometrial lesions determine the diagnostic symptom panel for a specific symptom. Methods: We recruited 537 women with endometriosis who underwent laparoscopic surgery. Data on patient characteristics, severity of pelvic pain symptoms, disease stage and anatomical characteristics of endometriotic lesions were collected and analyzed by univariate analysis, followed by multiple logistic regression. Results: We observed a strong inverse relationship between pain symptoms and, respectively, the age of women at surgery (OR 0.885; p<0.05) and nulliparity (OR 5.6; p<0.05). A significant association between dysmenorrhea and nulliparity (OR 10.1; p< 0.01) and dysmenorrhea and rAFS stage (OR 4.7; p<0.05) was also confirmed. Finally a strong relationship was found between the presence of a rectovaginal endometriotic nodule and pain symptoms: dyspareunia (OR 13.8, p<0.001) and dysmenorrhea (OR 2.3, p<0.05). Significant relationships were found between the presence of peri-annexial adherences and, respectively, bilateral endometrioma (p<0.01) and size of endometrioma (p<0.05); between the presence of pelvic adherential syndrome and, respectively, bilateral ovarian cyst (p<0.01), size of ovarian cyst (p<0.01) and rectovaginal nodule (p<0.01). A strong relationship was found also between a rectovaginal nodule and the presence of entero-uterine adherences (p<0.01) and Douglas obliteration (p<0.01). Conclusions: It was not possible determine a precise relationship between a specific pain symptom and the anatomic-surgical characteristics of endometriotic lesions, even though a strong association was seen between a rectovaginal endometriotic nodule and deep dyspareunia. Typical clinical features of endometriosis are probably determined by the association of different characteristics of lesions and different pathogenic mechanisms. © 2010 Wichtig Editore

Attitudes Toward Randomized, Controlled Trials in Surgery: Opinions of Gynecologists of the Gruppo Italiano di Studio sull'Endometriosi

In order to assess barriers and the attitudes of gynecologists toward randomized controlled trials (RCT) in surgery for endometriosis, we identified 62 gynecologists affilliated with the Gruppo Italiano di Studio sull'Endometriosi and sent them a questionnaire. A total of 52 (83.9%) gynecologists completed and sent it back to the coordinating center. Most gynecologists strongly agreed or agreed that RCTs should be the study design of choice for evaluating surgical procedures, but 66% also strongly agree/agree that RCTs are best suited to nonsurgical setting. With regard to the feasibility of RCT in surgery, there was a high level (<50%) of agreement with the statement: RCTs are insufficiently funded; the surgical community gives to RCTs too low priority; patients are unlikely to accept random allocation. A total of 43% agree or strongly agree that there is often consensus on new procedures without the need for RCTs, but 49% disagree or strongly disagree. Considering the statements on methodological problems in conducting RCTs in surgery, the main one was that comparisons of new and standard surgical procedures are often basically flawed because they cannot be performed with equal skill. This analysis indicates that RCTs are perceived as an important choice in the development of surgical treatments. However lack of funding, the impression that patients are unlikely to accept randomization, and the idea that comparison of new and old surgical procedures is flawed by the lack of skill in new procedures are important barriers to RCT in this field