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.

108 Developing A Non-Biopsy Protocol for The Female Cohort 25-29 Years with Clinically Typical Fibroadenoma Conforming to Maxwell Criteria on Ultrasound – Our Peninsular Experience in Wirral

Introduction

The aim of this study was to introduce a non –biopsy protocol in our department for benign breast lump referrals confirmed as typical U2/3 fibroadenoma on imaging. Current UK guidance is not to biopsy sonographically typical fibroadenoma in women under 25 years. We have studied our population extending the radiological Maxwell criteria reflecting benign outcomes in 25-29 years cohort.

Method

Retrospectively data was collected of all women between 25-29 years of age undergoing core biopsies for ultrasound confirmed fibroadenoma between 2014 and 2019 over a period of five years. The number of cancers picked up was compared with the number of referrals and the discordance between radiological diagnosis of fibroadenoma and histopathological confirmation of malignancy was recorded.

Results

A total of 1707 referrals were made across five years. n = 175 image guided core biopsies were carried out for U2, U3, U4 lesions appearing as fibroadenoma on ultrasound. Out of these (n = 175), all lesions coded U2/3 (n = 165) based on Maxwell criteria on ultrasound were negative for cancer. U4 lesions on ultrasound were confirmed as cancers mimicking fibroadenoma(n = 10).

Conclusions

This retrospective audit of 1707 patients provides sound evidence for non-biopsy of typical fibroadenoma in 25–29 years cohort sonographic features meet strict criteria.

109 Game Changing Magnetic Experience in Rural and Urban Wirral Peninsula - Our Experience with Magseed Localisation of Impalpable Breast Tumours and Axillary Nodes

Introduction

Magseed is a novel localization technology in which a tiny seed is inserted to accurately mark the site of breast tumour. These can be detected intra-operatively by sentimag localization system. It aids localization of impalpable breast lesions improving margin clearance rates.

Method

A prospective study of first fifty Magseed localised breast tumour and axillary node excisions in Clatterbridge General Hospital.

Results

A total of 50 patients had 52 Magseed inserted. n = 14 was symptomatic, n = 35 was screen detected and n = 1 was an incidental finding on surveillance mammogram for a B3 lesion. 30 seeds were inserted on the right and 22 were inserted on the left (two were bilateral). 44 seeds were inserted under ultrasound guidance and the rest were targeted under stereo guidance (n = 8). Deployment of two resulted in malposition requiring wire localization. Mean age of subjects was 59.76 (range 31-81) years. Mean time to surgery after magseed insertion was 8.04 (range 1-27) days. Mean weight of the specimen was 48.57(range 10-264) gm. Mean size of the lesions was 20.32 (range 8-65) mm. Redo surgery for margin clearance was performed bringing the re-excision rate to 15.38% (n = 8).

Conclusions

We conclude that Magseed localization of breast tumours is a safe and reliable technique

107 COVID 19 - Developing A Second Brain for Axillary Conservation During the Pandemic By Extrapolating Evidence On Technical Trends Of Sentinel Node Staging Of Axilla Into A Streamlined Recommendation

Introduction

Axillary conservation is the way forward after game changing trials like ACOSOG Z0011, surrogate trials like IBCSG,AMAROS, ALMANAC, on-going POSNOC, and newbie ATNEC have decreased the need to fiddle with the axilla. Current standard is the utilisation of double technique with radioisotope and blue dye to decrease false negative rates for true sentinel node retrieval.

Method

Literature search on the topic in the last two decades.

Results

The search yielded 197 publications which were subjected to a meticulous review.

Conclusions

Single agent radioisotope is recommended in palpable and good biology breast tumours. Use of single agent blue dye can be standardised in axillary tail tumours. It is also recommended when isotope mapping is logistically not feasible or during pandemics like COVID 19 where looming infrastructure challenges are prevalent. Dual agent technique should be considered in previously treated breast and axilla, neoadjuvant chemotherapy cohort, bad tumour biology, high BMI and macromastia groups for true nodal retrieval. Optimal number of nodes taken out should not be more than three (n = 3). Lower axillary sampling of not more than 3 nodes is recommended for troubleshooting. Magnetic tracing can be used as an adjunct to either single agent (RI/BD) technique when there is failure to localise the sentinel node.

Abstract PS2-43: Innovating a magnetic experience on wirral peninsula in the United Kingdom- our experience with magseed localisation of impalpable breast tumours and axillary node for therapeutic surgery and staging

INTRODUCTION Magseed is a novel localization technology in which a tiny seed is inserted to accurately mark the site of breast tumour. These can be detected intra-operatively by sentimag localization system. These can be implanted days prior to surgery and do not require use of radioactive material. It aids localization of impalpable breast lesions improving margin clearance rates. METHODS A study was undertaken of 50 patients undergoing Magseed localization of non-palpable breast lesions in rural and urban areas of Wirral Peninsula in the UK. Data including age, mode of localization (Stereo-guided/ Ultrasound guided), presentation (Symptomatic/Screen detected), and time to surgery after localization, size and weight of specimen, histology and re-excision rates was collected between June 2019 and November 2019. RESULTS A total of 50 patients had 52 Magseed inserted. n=14 were symptomatic, n=35 were screen detected and n=1 was an incidental finding on surveillance mammogram for a B3 lesion. All 50 patients had therapeutic surgery. 30 seeds were inserted on the right and 22 were inserted on the left (two were bilateral). 44 seeds were inserted under Ultrasound guidance and the rest were targeted under stereo guidance (n=8).Deployment of 2 Magseed resulted in malposition requiring wire localization. Mean age of subjects was 59.76 (range 31-81) years. Mean time to surgery after Magseed insertion was 8.04 (range 1-27) days. Mean weight of the specimen was 48.57(range 10-264) gm. Mean size of the lesions was 20.32 (range 8-65) mm. Redo surgery for margin clearance was performed bringing the re-excision rate to 15.38% (n=8). CONCLUSION We conclude that Magseed localization of breast tumours is a safe and reliable technique in terms of accuracy, localization and clearance of margins without any radiation concerns. Our re-excision rate for margin clearance is comparable to the national average. The only caveat we observed was localization of impalpable lesions prior to surgery in bulky breasts where we had to utilize wire guided localization on the day of surgery. Large scale data are lacking to compare Magseed localization with other localization techniques for non-palpable breast lesions.

Citation Format: Tahera Arif, Mohammed Shameem Absar, Jonathan Michael Lund. Innovating a magnetic experience on wirral peninsula in the United Kingdom- our experience with magseed localisation of impalpable breast tumours and axillary node for therapeutic surgery and staging [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-43.

Abstract PS2-39: A peninsular experience - developing a non-biopsy protocol for the female cohort 25-29 years with clinically typical fibroadenoma conforming to maxwell criteria on ultrasound

Abstract.Abstract1:

IntroAim: The aim of this study was to introduce a non -biopsy protocol in our department for benign breast lump referrals confirmed as typical U2/3 fibroadenoma on imaging. The cohort of women between 25-29 years of age with sonographic features (Maxwell non-biopsy criteria) U2/3 typical of fibroadenoma does not miss malignancy. Current UK guidance is not to biopsy sonographically typical fibroadenomas in women under 25 years. We have studied our population extending the radiological Maxwell criteria reflecting histologically benign outcomes even in this group of 25-29 years.MethodsMethods: Retrospectively data was collected of all women between 25-29 years of age undergoing core biopsy for ultrasound confirmed both simple and complex fibroadenomas at Clatterbridge General Hospital between 2014 and 2019 over a period of five years. The number of cancers picked up was compared with the number of referrals and the discordance between radiological diagnosis of fibroadenoma and histopathological confirmation of malignancy was recorded.ResultsResults: We saw increment in referrals in this group of young women from n=260 to n=386 over the five year study period. A total of 1707 referrals were made across five years. n=175 image guided core biopsies were carried out for U2,U3,U4 lesions appearing as fibroadenoma on ultrasound. Out of these (n=175), all lesions coded U2/3 (n=165) based on Maxwell criteria on ultrasound were negative for cancer. U4 lesions on ultrasound were confirmed as cancers mimicking fibroadenoma(n=10).ConclusionConclusion: This retrospective audit of 1707 patients provides sound evidence for safe non-biopsy of typical fibroadenomas in women 25-29 years when clinical and sonographic features meet strict criteria. We started using the non-biopsy protocol using Maxwell criteria for U2/3 lesions. We discharged women in this group if they met all the protocol criteria, i.e., their lesion does not appear suspicious clinically, has all the ultrasound appearances typical of a fibroadenoma U2/3, and they do not have any compounding circumstances (e.g., family history, genetic predisposition). As routine, we advise all women who are discharged without follow-up to examine their breasts regularly and return if they detect any changes including increase in lesion size. We need data to be audited prospectively and provide level 1 evidence to the same effect.

Citation Format: Tahera Arif, Mohammed Shameem Absar, Raman Vinayagam. A peninsular experience - developing a non-biopsy protocol for the female cohort 25-29 years with clinically typical fibroadenoma conforming to maxwell criteria on ultrasound [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-39.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Bimetallic gold(i) complexes of photoswitchable phosphines: synthesis and uses in cooperative catalysis

The first photoswitchable bimetallic gold catalysts based on an azobenzene backbone have been synthesized and their catalytic properties have been investigated.

Position dependent changes of cerebral blood flow velocities in premature infants

The supine or prone positioning of infants has been a cause of much controversy. Recently it has been postulated that the position dependent hypoperfusion of the brainstem represents a possible cause of sudden infant death. To demonstrate position dependency and maturational changes of cerebral perfusion in premature newborn infants we investigated cerebral blood flow velocities (CBFV) in the main supratentorial and brainstem cerebral arteries. Measurements of CBFV were done with transfontanellar colour-coded Doppler sonography in the internal carotid artery (ICA), basilar artery (BA), and vertebral artery (VA) in the prone (head centered-baseline) and supine positions (maximal rotation to both sides) in 23 premature infants aged between 3-5 days of life. We performed follow-up measurements in 17 infants 7-10 days later and in 16 infants at the corrected age of 1 month. There was no difference in mean CBFVs between the prone and supine position at the first investigation. At the third investigation, CBFVs were significantly higher in the supine compared to the prone position. The CBFVs of the ICA were higher than in the BA and VA. This difference was not influenced by the body position but increased with post-natal age more in the VA (159%) than in the BA (129%) and ICA (128%). Position dependency was not seen in the ICA perfusion. In the prone position, five infants showed an incomplete steal effect in the contralateral VA. There was no significant side difference in the CBFVs of the ICA and VA, but in the resistance indices in the VA (left > right).

CONCLUSION

in premature newborns, position dependent changes of cerebral blood flow velocity develop with maturation and are most pronounced in the vertebrobasilar system. These changes are possibly due to compression of the vertebral artery by neck movement and suggest an individual risk of brainstem perfusion deficits that may be aggravated with age and head rotation in a prone position.

Measurement of urinary melatonin: a useful tool for monitoring serum melatonin after its oral administration

The relevance of measuring urinary melatonin (MLT) for human pineal research is sometimes questioned, and the relationship among serum levels of MLT, urinary excretion of the unmetabolized hormone, and excretion of MLTs main metabolite, 6-hydroxymelatonin sulfate (aMT6s), is still uncertain. We applied a well established RIA for measuring MLT in serum to urine samples, characterized its criteria of performance in this body fluid, and used it for human studies. In 16 adolescents, the endogenous overnight MLT secretion, expressed as the area under the concentration time curve, correlated significantly with the amounts of urinary aMT6s (r = 0.86; P < 0.0001) and urinary MLT (r = 0.70; P = 0.0027) excreted during a 16-h observation period. Oral administration of 3 mg exogenous MLT in 17 healthy volunteers resulted in peak MLT serum levels differing 28-fold among subjects (940-27,240 pg/ mL; range). In this study urinary MLT, but not aMT6s, excretion was associated with blood MLT concentrations (r = 0.76; P = 0.0004 vs. r = 0.02; P = 0.93, respectively). Thus, endogenous MLT production can be assessed accurately by measuring either aMT6s or MLT excretion. After oral application of MLT, however, only measurement of MLT excretion is a reliable marker of serum concentrations. Determination of MLT in urine may prove to be a useful tool for drug monitoring after oral administration of the pineal hormone.

Mothers' attitudes to children's chest infections in India

Acute Respiratory Infections (ARIs) account for a very high morbidity and mortality amongst children in the developing countries. A knowledge, attitude and practice study in relation to the literacy status of mothers whose children suffered from ARI was conducted. A sample of 140 mothers who had 265 children were selected for the study. The majority of literate mothers (75%) had complete knowledge regarding management of ARI. Literacy alone was not the only factor responsible for developing a positive attitude and adopting correct practices during ARI. Mass media and health personnel played an equally important role. Most women (89.3%) had obtained their knowledge regarding ARI through media and paramedical staff. Most mothers (96.4%) were concerned about the health of their children when they suffered from episodes of ARI and the majority of them (87.2%) were worried because they felt that their children or contacts could be adversely affected. Nearly 72% of mothers took early action during an episode of ARI. The majority of the medical practitioners practised non-allopathic medicine but all of them were prescribing allopathic drugs. Most of the mothers (70%) had no problem in taking their children to the desired health centers when needed.