Uncertainties and opportunities in delivering environmentally sustainable surgery:the surgeons' view

Surgery is a carbon‐heavy activity and creates a high volume of waste. Surgical teams around the world want to deliver more environmentally sustainable surgery but are unsure what to do and how to create change. There are many interventions available, but resources and time are limited. Capital investment into healthcare and engagement of senior management are challenging. However, frontline teams can change behaviours and drive wider change. Patients have a voice here too, as they would like to ensure their surgery does not harm their local community but are concerned about the effects on them when changes are made. Environmentally sustainable surgery is at the start of its journey. Surgeons need to rapidly upskill their generic knowledge base, identify which measures they can implement locally and take part in national research programmes. Surgical teams in the NHS have the chance to create a world‐leading programme that can bring change to hospitals around the world. This article provides an overview of how surgeons see the surgical team being involved in environmentally sustainable surgery

Gellan gum: a new biomaterial for cartilage tissue engineering applications

Gellan gum is a polysaccharide manufactured by microbial fermentation of the Sphingomonas paucimobilis microorganism, being commonly used in the food and pharmaceutical industry. It can be dissolved in water, and when heated and mixed with mono or divalent cations, forms a gel upon lowering the temperature under mild conditions. In this work, gellan gum hydrogels were analyzed as cells supports in the context of cartilage regeneration. Gellan gum hydrogel discs were characterized in terms of mechanical and structural properties. Transmission electron microscopy revealed a quite homogeneous chain arrangement within the hydrogels matrix, and dynamic mechanical analysis allowed to characterize the hydrogels discs viscoelastic properties upon compression solicitation, being the compressive storage and loss modulus of !40 kPa and 3 kPa, respectively, at a frequency of 1 Hz. Rheological measurements determined the sol-gel transition started to occur at approximatel 368C, exhibiting a gelation time of !11 s. Evaluation of the gellan gum hydrogels biological performance was performed using a standard MTS cytotoxicity test, which showed that the leachables released are not deleterious to the cells and hence were noncytotoxic. Gellan gum hydrogels were afterwards used to encapsulate human nasal chondrocytes (1 3 106 cells/mL) and culture them for total periods of 2 weeks. Cells viability was confirmed using confocal calcein AM staining. Histological observations revealed normal chondrocytes morphology and the obtained data supports the claim that this new biomaterial has the potential to serve as a cell support in the field of cartilage regeneration.Contract grant sponsor: The Portuguese Foundation for Science and Technology (FCT); contract grant number: SFRH/BD17135/2004Contract grant sponsor: The European NoE EXPERTIS-SUES; contract grant number: NMP3-CT-2004-500283Contract grant sponsor: The European Project HIPPO-CRATES; contract grant number: STRP 505758-

Gellan gum injectable hydrogels for cartilage tissue engineering applications: in vitro studies and preliminary in vivo evaluation

Gellan gum is a polysaccharide that we have previously proposed for applications in the cartilage tissue engineering field. In this work, gellan gum hydrogels were tested for their ability to be used as injectable systems using simple processing methods, able to deliver and maintain chondrocytes by in situ gelation, and support cell viability and production of extracellular matrix (ECM). Rheological measurements determined that the sol–gel transition occurred near the body temperature at 39ºC, upon temperature decrease, in approximately 20 s. Gellan gum discs shows a storage compression modulus of around 80 kPa at a frequency of 1Hz by dynamic mechanical analysis. Human articular chondrocytes were encapsulated in the gels, cultured in vitro for total periods of 56 days, and analyzed for cell viability and ECM production. Calcein AM staining showed that cell kept viable after 14 days and the histological analysis and real-time quantitative polymerase chain reaction revealed that hyaline-like cartilage ECM was synthesized. Finally, the in vivo performance of the gellan gum hydrogels, in terms of induced inflammatory reaction and integration into the host tissue, was evaluated by subcutaneous implantation in Balb/c mice for 21 days. Histological analysis showed a residual fibrotic capsule at the end of the experiments. Dynamic mechanical analysis revealed that the gels were stable throughout the experiments while evidencing a tendency for decreasing mechanical properties, which was consistent with weight measurements. Altogether, the results demonstrate the adequacy of gellan gum hydrogels processed by simple methods for noninvasive injectable applications toward the formation of a functional cartilage tissue-engineered construct and originally report the preliminary response of a living organism to the subcutaneous implantation of the gellan gum hydrogels. These are the two novel features of this work.J. T. Oliveira would like to acknowledge the Portuguese Foundation for Science and Technology for his grant (SFRH/BD17135/2004). The authors would like to thank the patients at Hospital de S. Marcos, Braga, Portugal for the donation of the biological samples, and the medical staff for their help and support. The authors would also like to thank the Institute for Health and Life Sciences, University of Minho, Braga, Portugal, for allowing the use of their research facilities. This work was carried out under the scope of the European NoE EXPERTISSUES (NMP3-CT-2004 500283) and partially supported by the European Project HIPPOCRATES (STRP 505758-1)

Surgical multicenter collaborative studies: ¿What happen in Latin America?

Antecedentes: GlobalSurg es un grupo internacional de investigadores que tiene como propósito la conducción y la diseminación de robustos estudios colaborativos, internacionales y multicéntricos. Objetivo: Exponer las estrategias necesarias y las barreras encontradas en la conducción de estudios multicéntricos masivos en cirugía. Método: Durante el segundo semestre del año 2020 se llevó a cabo el estudio Surg-Week Prospective International Cohort Study, hasta la fecha el estudio internacional más grande en el campo de la cirugía, con 141,582 pacientes incluidos. Un total de 4975 miniequipos, de uno a cinco integrantes, recopilaron datos de 116 países de todos los continentes. Resultados: La creación de un sitio web oficial del estudio, reportes con información relevante vía e-mail o grupos vía WhatsApp, conformación de un comité de diseminación del protocolo, dictado de webinars sobre publicaciones recientes del equipo, designación de líderes nacionales e internacionales, y la divulgación por medio de sociedades, fueron las estrategias utilizadas para el desarrollo de la investigación. Sin embargo, las barreras detectadas para llevar a cabo el estudio multicéntrico fueron variadas. Conclusiones: Los trabajos colaborativos permiten establecer redes entre diferentes profesionales con el fin de mejorar la calidad de la gestión, las políticas sanitarias y la atención a los pacientes en tiempos de constante cambio.Background: GlobalSurg is an international group of researchers whose purpose is to conduct and disseminate robust collaborative, international and multicenter studies. Objective: To expose the necessary strategies and the barriers crossed in conducting massive multicenter studies in surgery. Method: During the second semester of 2020, the study Surg-Week Prospective International Cohort Study was carried out. Surg-Week has been the largest international study in the field of surgery to date, with 141,582 patients included. A total of 4975 mini-teams, of between 1 and 5 members, collected data from 116 countries on all continents. Results: The creation of an official website for the study, reports with relevant information via email or groups via WhatsApp, formation of a Dissemination Committee of the protocol, delivery of webinars on recent team publications, appointment of leaders at the national and international level, and outreach through partnerships, were the strategies used for the development of the research. However, the barriers turned out to involve different aspects. Conclusions: Collaborative work allows establishing networks between different professionals with the goal of improving the quality of management, health policies and care of our patients in a timely manner of constant change

Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries

Background: The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. Methods: First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. Findings: In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1–84·9), which varied between HIC (88·5 [89·0–88·0]), MIC (81·8 [82·5–81·1]), and LIC (66·8 [64·9–68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0–4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1–5·5]; p<0·0001), MIC (2·8 [2·0–3·7]; p<0·0001), and LIC (3·8 [1·3–6·7%]; p<0·0001) settings. Interpretation: The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs. Funding: National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic

Global wealth disparities drive adherence to COVID-safe pathways in head and neck cancer surgery

Peer reviewe

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18–49, 50–69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population