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

Venous Thromboembolism Following Major Abdominal Surgery for Cancer: A Guide for the Surgical Intern.

BACKGROUND: Venous thromboembolism (VTE) is a term used to compositely describe deep vein thrombosis (DVT) and pulmonary embolism (PE). Overall, the incidence of VTE after major abdominal and pelvic surgery has been reported to be between 10% and 40%. OBJECTIVE: To estimate the incidence of post-operative VTE in patients undergoing major abdominal surgery for cancer, to identify risk factors associated with VTE, and to assess available thromboprophylaxis tools. METHODS: A Medline and Cochrane literature search from database inception until February 1st, 2021 was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS: Thirty-one studies met our eligibility criteria and were included in the current review. In total, 435,492 patients were identified and the overall incidence of VTE was 2.19%( 95% CI: 1.82-2.38). Τhe following risk factors were associated with VTE: smoking, advanced age (>70 years), a history of diabetes mellitus, American Society of Anesthesiologists’ (ASA) classification of Physical Health class III or IV, a history of cardiovascular or pulmonary disease, a history of DVT or PE, elevated plasma fibrinogen level, c-reactive protein (CRP) level, cancer stage III or IV, postoperative acute respiratory distress syndrome (ARDS), prolonged postoperative hospital stay, previous steroid use, history of Inflammatory Bowel Disease (IBD), heart failure and neoadjuvant and adjuvant chemotherapy. CONCLUSION: VTE remains an important complication after major abdominal surgery for cancer and seems to increase mortality rates

Myocardial infarction after esophagectomy for esophageal cancer: A systematic review

Background Esophagectomy remains the most effective treatment modality for esophageal cancer. However, esophagectomy is associated with several postoperative complications, including anastomotic leak, new-onset atrial fibrillation, pneumonia, venous thromboembolism events, and myocardial infarction. In this systematic review of the literature, we aim to assess the incidence of myocardial infarction in patients with esophageal cancer undergoing esophagectomy and to identify possible risk factors for myocardial infarction. Methods A systematic search of the English-language medical literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (end of search: September 30, 2020). Results A total of 14 studies met our inclusion criteria for the current review. Overall, 3673 patients who underwent esophagectomy were identified. Among them, 70 (1.9%) developed myocardial infarction postoperatively. The following risk factors were reported in the individual studies: age, previous myocardial infarction, ventricular arrythmia, smoking, chronic obstructive pulmonary disease, diabetes mellitus, thromboembolic disease, hypertension, and heart failure. Conclusion Myocardial infarction remains an important complication after esophageal surgery. Further investigations are needed to better understand the risk factors and optimum management for post-esophagectomy myocardial infarction

Antibiotics exposure and risk of inflammatory bowel disease: a systematic review

<p><b>Aim:</b> The aim of this study was to critically assess all available evidence suggesting an association between antibiotic exposure and new onset of inflammatory bowel disease (IBD).</p> <p><b>Materials and methods:</b> This systematic review was conducted according to the PRISMA statement and eligible studies were identified through search of PubMed, Embase and the Cochrane Library. Data on patient demographics, antibiotic exposure and confounding factors were analyzed. The Newcastle-Ottawa Scale (NOS) was used to assess the quality of eligible studies.</p> <p><b>Results:</b> A total of 15 observational studies (10 case control and five cohort) including 8748 patients diagnosed with IBD were systematically reviewed. Antibiotic exposure was mostly associated with Crohn’s disease but not with ulcerative colitis. In particular, penicillin’s, cephalosporins, metronidazole and fluoroquinolones were most commonly associated with the onset of Crohn’s disease. The impact of tetracycline-family antibiotics on the pathogenesis of IBD was not clear.</p> <p><b>Conclusion:</b> There may be an association between antibiotic exposure and the development of IBD; especially Crohn’s disease. Even though, clinicians should be cautious when prescribing certain antibiotic regimens to patients with a strong family history of IBD, it should be emphasized that available data are not granular enough to reach any definitive conclusions.</p

Gastrectomy for Cancer: A 15-Year Analysis of Real-World Data from the University of Athens

Background and Objectives: Encouraging data have been reported from referral centers following gastrointestinal cancer surgery. Our goal was to retrospectively review patient outcomes following gastrectomy for gastric or gastroesophageal junction (GEJ) cancer at a high-volume unit of the University of Athens. Methods: The enrollment period was from June 2003 to September 2018. Disease-free survival (DFS) and overall survival (OS) were estimated using the Kaplan-Meier method. Cox proportional hazard models were constructed to identify variables independently associated with time-to-event outcomes. Results: A total of 205 patients were analyzed. R0 resection was achieved in 183 (89.3%) patients and was more likely to occur following neoadjuvant chemotherapy (p = 0.008). Recurrence developed in 46.6% of our cohort and the median disease-free survival was 31.2 months. On multivariate analysis, only staging (HR = 2.15; 95% CI: 1.06&ndash;4.36) was independently associated with increased risk of recurrence. All-cause mortality was 57.2% and the median time of death was 40.9 months. On multivariate regression, staging (HR: 1.35; 95% CI: 1.11&ndash;1.65) and recurrence (HR: 2.87; 95% CI: 1.32&ndash;6.22) predicted inferior prognosis. Conclusions: Gastrectomy at the University of Athens has yielded favorable outcomes for patients with GEJ cancer

Acute esophageal necrosis: A systematic review and pooled analysis

BACKGROUND Acute esophageal necrosis (AEN) is a rare entity with multifactorial etiology, usually presenting with signs of upper gastrointestinal bleeding. AIM To systematically review all available data on demographics, clinical features, outcomes and management of this medical condition. METHODS A systematic literature search was performed with respect to the PRISMA statement (end-of-search date: October 24, 2018). Data on the study design, interventions, participants and outcomes were extracted by two independent reviewers. RESULTS Seventy-nine studies were included in this review. Overall, 114 patients with AEN were identified, of whom 83 were males and 31 females. Mean patient age was 62.1 +/- 16.1. The most common presenting symptoms were melena, hematemesis or other manifestations of gastric bleeding (85%). The lower esophagus was most commonly involved (92.9%). The most widely implemented treatment modality was conservative treatment (75.4%), while surgical or endoscopic intervention was required in 24.6% of the cases. Mean overall follow-up was 66.2 +/- 101.8 d. Overall 29.9% of patients died either during the initial hospital stay or during the follow-up period. Gastrointestinal symptoms on presentation [Odds ratio 3.50 (1.09-11.30), P = 0.03] and need for surgical or endoscopic treatment [surgical: Odds ratio 1.25 (1.03-1.51), P = 0.02; endoscopic: Odds ratio 1.4 (1.17-1.66), P &lt; 0.01] were associated with increased odds of complications. A sub-analysis separating early versus late cases (after 2006) revealed a significantly increased frequency of surgical or endoscopic intervention (9.7 % vs 30.1% respectively, P = 0.04) CONCLUSION AEN is a rare condition with controversial pathogenesis and unclear optimal management. Although the frequency of surgical and endoscopic intervention has increased in recent years, outcomes have remained the same. Therefore, further research work is needed to better understand how to best treat this potentially lethal disease