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

Laparoscopic Versus Open Sigmoid Loop Colostomy: A Comparative Study from a Cohort of 62 Patients Requiring Temporary Faecal Diversion at a Tertiary Care Center in North India

Background: Over decades, colostomies have been done through open method, but laparoscopic creation of an intestinal stoma is safe, feasible and has distinct advantages over conventional techniques in specific procedures. The aim of this study compares operative and short-term outcomes of laparoscopic and open sigmoid loop colostomy formation for temporary fecal diversion. Subjects and Methods: A single institution, comparative study conducted in the department of surgery for patients who underwent either laparoscopic or open sigmoid loop colostomy. The 2 years' study was from December 1, 2013, to November 30, 2015. Subjects were prospectively enrolled in the study after informed consent, both genders of >12 years of age. Data analysis was done using Statistical Package for Social Sciences version 21.0. Variables were tested by Kolmogorov–Smirnov test, compared using unpaired t-test/Mann–Whitney Test, Chi-square test/Fisher's exact test. P < 0.05 was considered statistically significant. Results: Sixty-two patients were enrolled; laparoscopy group – 29 patients (46.77%) versus open group – 33 patients (53.22%). Laparoscopic group/open surgery group showed less blood loss (20.69 + 17.71 ml / 121.97 + 35.29ml, P-value 0.0005), lower requirement of analgesics (4.28 ± 1.76 days/6.88 ± 2.75 days), shorter hospital stay (8.79 ± 5.57 days and 11.73 ± 6.61 days, P = 0.001), early return of the bowel function and tolerance to diet. Complications and readmission requirement for any complication was lower in the laparoscopic group. Conclusions: Laparoscopic sigmoid loop colostomy is a simple alternative to open sigmoid loop colostomy with respect to postoperative pain, earlier return of bowel function, lower analgesic requirement, and lesser hospital stay

Management of low-grade malignant dermatofibrosarcoma protuberans without compromising oncologic clearance despite financial constraints

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive soft-tissue tumor with high recurrence. Tissue biopsy, imaging, and staging form the diagnostic pathway, but sometimes investigations deter patients from low socioeconomic background. We present a case of malignant DFSP with adequate oncologic clearance despite financial constraints. A young male presented with a swelling over the right hip for 8 years. Although fine-needle aspiration, core biopsy, magnetic resonance imaging, and staging computerized axial tomography scan are the ideal management pathway, the patient refused these for an excision biopsy which would have sufficed if histology was benign. Histology reported a malignant fibrosarcomatous variant of DFSP. Wide excision of previous biopsy site and flap reconstruction was done as advised by the skin oncology multidisciplinary team (MDT) which confirmed oncologic clearance. We would ideally advocate a proper oncologic pathway, but in patients where finances restrict investigations oncologic clearance can still be achieved

Arsenic exposure in drinking water: an unrecognized health threat in Peru

OBJECTIVE: To assess the extent of arsenic contamination of groundwater and surface water in Peru and, to evaluate the accuracy of the Arsenic Econo-Quick(™) (EQ) kit for measuring water arsenic concentrations in the field. METHODS: Water samples were collected from 151 water sources in 12 districts of Peru, and arsenic concentrations were measured in the laboratory using inductively-coupled plasma mass spectrometry. The EQ field kit was validated by comparing a subset of 139 water samples analysed by laboratory measurements and the EQ kit. FINDINGS: In 86% (96/111) of the groundwater samples, arsenic exceeded the 10 µg/l arsenic concentration guideline given by the World Health Organization (WHO) for drinking water. In 56% (62/111) of the samples, it exceeded the Bangladeshi threshold of 50 µg/l; the mean concentration being 54.5 µg/l (range: 0.1–93.1). In the Juliaca and Caracoto districts, in 96% (27/28) of groundwater samples arsenic was above the WHO guideline; and in water samples collected from the section of the Rímac river running through Lima, all had arsenic concentrations exceeding the WHO limit. When validated against laboratory values, the EQ kit correctly identified arsenic contamination relative to the guideline in 95% (106/111) of groundwater and in 68% (19/28) of surface water samples. CONCLUSION: In several districts of Peru, drinking water shows widespread arsenic contamination, exceeding the WHO arsenic guideline. This poses a public health threat requiring further investigation and action. For groundwater samples, the EQ kit performed well relative to the WHO arsenic limit and therefore could provide a vital tool for water arsenic surveillance

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80-100%) vs low (21-35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with 222 for low FiO2 leading to a -6 (95% confidence interval [CI]: -13 to -1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a -$11 (95$15 to -$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with 1257 for low FiO2 leading to a -93 (95% CI: -132 to -65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a -1.05 (95% CI: -1.14 to -0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this

Adaptation of the Wound Healing Questionnaire universal-reporter outcome measure for use in global surgery trials (TALON-1 study): mixed-methods study and Rasch analysis

BackgroundThe Bluebelle Wound Healing Questionnaire (WHQ) is a universal-reporter outcome measure developed in the UK for remote detection of surgical-site infection after abdominal surgery. This study aimed to explore cross-cultural equivalence, acceptability, and content validity of the WHQ for use across low- and middle-income countries, and to make recommendations for its adaptation.MethodsThis was a mixed-methods study within a trial (SWAT) embedded in an international randomized trial, conducted according to best practice guidelines, and co-produced with community and patient partners (TALON-1). Structured interviews and focus groups were used to gather data regarding cross-cultural, cross-contextual equivalence of the individual items and scale, and conduct a translatability assessment. Translation was completed into five languages in accordance with Mapi recommendations. Next, data from a prospective cohort (SWAT) were interpreted using Rasch analysis to explore scaling and measurement properties of the WHQ. Finally, qualitative and quantitative data were triangulated using a modified, exploratory, instrumental design model.ResultsIn the qualitative phase, 10 structured interviews and six focus groups took place with a total of 47 investigators across six countries. Themes related to comprehension, response mapping, retrieval, and judgement were identified with rich cross-cultural insights. In the quantitative phase, an exploratory Rasch model was fitted to data from 537 patients (369 excluding extremes). Owing to the number of extreme (floor) values, the overall level of power was low. The single WHQ scale satisfied tests of unidimensionality, indicating validity of the ordinal total WHQ score. There was significant overall model misfit of five items (5, 9, 14, 15, 16) and local dependency in 11 item pairs. The person separation index was estimated as 0.48 suggesting weak discrimination between classes, whereas Cronbach's α was high at 0.86. Triangulation of qualitative data with the Rasch analysis supported recommendations for cross-cultural adaptation of the WHQ items 1 (redness), 3 (clear fluid), 7 (deep wound opening), 10 (pain), 11 (fever), 15 (antibiotics), 16 (debridement), 18 (drainage), and 19 (reoperation). Changes to three item response categories (1, not at all; 2, a little; 3, a lot) were adopted for symptom items 1 to 10, and two categories (0, no; 1, yes) for item 11 (fever).ConclusionThis study made recommendations for cross-cultural adaptation of the WHQ for use in global surgical research and practice, using co-produced mixed-methods data from three continents. Translations are now available for implementation into remote wound assessment pathways