Society for Surgery of the Alimentary Tract State-of-the-Art Session 2022: Frailty in Surgery.

Given the exponentially aging population and rising life expectancy in the United States, surgeons are facing a challenging frail population who may require surgery but may not qualify based on their general fitness. There is an urgent need for greater awareness of the importance of frailty measurement and the implementation of universal assessment of frail patients into clinical practice. Pairing risk stratification with stringent protocols for prehabilitation and minimally invasive surgery and appropriate enhanced recovery protocols could optimize and condition frail patients before, during, and immediately after surgery to mitigate postoperative complications and consequences on patient function and quality of life. In this paper, highlights from the 2022 Society for Surgery of the Alimentary Tract State-of-the-Art Session on frailty in surgery are presented. This work aims to improve the understanding of the impact of frailty on patients and the methods used to augment the outcomes for frail patients during their surgical experience.

Comparison of Prognostic Factors for Merkel Cell Carcinoma, Mucosal Melanoma and Cutaneous Malignant Melanoma: Insights into Their Etiologies.

Little is known about the epidemiology of Merkel cell carcinoma (MCC) and mucosal melanoma (MM). Using the United States (US) National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program data, we compared MCC and MM with cutaneous malignant melanoma (CMM) with respect to incidence rates and prognostic factors to better understand disease etiologies. We describe the proportional incidences of the three cancers along with their survival rates based on 20 years of national data. The incidence rates in 2000-2019 were 203.7 per 1,000,000 people for CMM, 5.9 per 1,000,000 people for MCC and 0.1 per 1,000,000 people for MM. The rates of these cancers increased over time, with the rate of MM tripling between 2000-2009 and 2010-2019. The incidences of these cancers increased with age and rates were highest among non-Hispanic Whites. Fewer MCCs and MMS were diagnosed at the local stage compared with CMM. The cases in the 22 SEER registries in California were not proportional to the 2020 population census but instead were higher than expected for CMM and MCC and lower than expected for MM. Conversely, MM rates were higher than expected in Texas and New York. These analyses highlight similarities in the incidence rates of CMM and MCC-and differences between them and MM rates-by state. Understanding more about MCC and MM is important because of their higher potential for late diagnosis and metastasis, which lead to poor survival.

The Association between Serum Albumin and Post-Operative Outcomes among Patients Undergoing Common Surgical Procedures: An Analysis of a Multi-Specialty Surgical Cohort from the National Surgical Quality Improvement Program (NSQIP).

While studies have demonstrated an association between preoperative hypoalbuminemia and adverse clinical outcomes, the optimal serum albumin threshold for risk-stratification in the broader surgical population remains poorly defined. We sought define the optimal threshold of preoperative serum albumin concentration for risk-stratification of adverse post-operative outcomes. Using the American College of Surgeons National Surgical Quality Improvement Program Database, we identified 842,672 patients that had undergone a common surgical procedure in one of eight surgical specialties. An optimal serum albumin concentration threshold for risk-stratification was determined using receiver-operating characteristic analysis. Multivariable logistic regression analysis was used to evaluate the odds of adverse surgical events; a priori defined subgroup analyses were performed. A serum albumin threshold of 3.4 g/dL optimally predicted adverse surgical outcomes in the broader cohort. After multivariable analysis, patients with hypoalbuminemia had increased odds of death within 30 days of surgery (odds ratio [OR] 2.01, 95% confidence interval [CI] 1.94-2.08). Hypoalbuminemia was associated with greater odds of primary adverse events among patients with disseminated cancer (OR 2.03, 95% CI 1.88-2.20) compared to patients without disseminated cancer (OR 1.47, 95% CI 1.44-1.51). The standard clinical threshold for hypoalbuminemia is the optimal threshold for preoperative risk assessment.

The Impact of Frailty on Patients Undergoing Liver Resection for Colorectal Liver Metastasis.

BACKGROUND: The aim of this study is to assess the impact of frailty on short-term outcomes after hepatectomy for colorectal liver metastasis (CRLM). METHODS: Patients were identified using the National Surgical Quality Improvement Program (NSQIP). Patients were divided into 3 categories using the 5-item Modified Frailty Index (mFI). RESULTS: There were 5230 patients included. 52%, 35%, and 13% had mFI scores of 0, 1, and ≥ 2 respectively. Patients with a ≥ 2 mFI score were more likely to experience minor complication (OR 1.34, 95% CI 1.06-1.69), major complication (OR 1.56, 95% CI 1.15-2.12), readmission (OR 1.55, 95% CI 1.12-2.14), unfavorable discharge (OR 2.48, 95% CI 1.62-3.80), 30-day mortality (OR 3.02, 95% CI 1.02-8.95), prolonged length of stay (OR 1.47, 95% CI 1.18-1.83), and bile leak (OR 1.51, 95% CI 1.02-2.24). CONCLUSION: Frailty is associated with increased post-operative complications. The 5-item mFI can guide risk stratification, optimization, and counseling.

Detailed Assessment of Pet Ownership Rates in Four Underserved Urban and Rural Communities in the United States.

Understanding pet ownership in a community is an important factor for assessing the effectiveness of animal welfare programming. Data on pet ownership were collected from 2,327 households in two urban and two rural zip codes. The percentage of households owning pets and the species owned were calculated for the individual communities, the urban and rural pairs, and the aggregate data. Findings were compared to the 2017-2018 AVMA Pet Ownership and Demographics Sourcebook data. The rural communities had an 11.5% higher rate of overall pet keeping and a 19% higher dog ownership rate than the urban communities, but the measured cat ownership rate was similar in all four sites at an average of 19.4% (SD = 2.1%). The community-specific rates of pet ownership were different (p < .0001) than the rates predicted fromthe AVMA-recommended formula, but at 56.8%, the aggregate pet-keeping rate was exactly the same as that calculated by the AVMA. The findings reveal community-level variability in pet-keeping rates that must be accounted for when assessing pet service, emergency planning, and animal welfare programming needs.

Does Preoperative Estimated Glomerular Filtration Rate (eGFR) Predict Short-Term Surgical Outcomes in Patients Undergoing Pancreatic Resections?

INTRODUCTION: Preoperative eGFR has been found to be a reliable predictor of post-operative outcomes in patients with normal creatinine levels who undergo surgery. The aim of our study was to evaluate the impact of preoperative eGFR levels on short-term post-operative outcomes in patients undergoing pancreatectomy. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) pancreatectomy file (2014-2017) was queried for all adult patients (age ≥ 18) who underwent pancreatic resection. Patients were stratified into two groups based on their preoperative eGFR (eGFR < 60 mL/min/1.73m2 and eGFR ≥ 60 mL/min/1.73m2). Outcome measures included post-operative pancreatic fistula, discharge disposition, hospital length of stay, 30-day readmission rate, and 30-day morbidity and mortality. Multivariate logistic regression analysis was performed. RESULTS: A total of 21,148 were included in the study of which 12% (n = 2256) had preoperative eGFR < 60 mL/min/1.73m2. Patients in the eGFR < 60 group had prolonged length of stay, were less likely to be discharged home, had higher minor and major complication rates, and higher rates of mortality. On logistic regression analysis, lower preoperative eGFR (< 60 mL/min/1.73m2) was associated with higher odds of prolonged length of stay [aOR: 1.294 (1.166-1.436)], adverse discharge disposition [aOR: 1.860 (1.644-2.103)], minor [aOR: 1.460 (1.321-1.613)] and major complications [aOR: 1.214 (1.086-1.358)], bleeding requiring transfusion [aOR: 1.861 (1.656-2.091)], and mortality [aOR: 2.064 (1.523-2.797)]. CONCLUSION: Preoperative decreased renal function measured by eGFR is associated with adverse outcomes in patients undergoing pancreatic resection. The results of this study may be valuable in improving preoperative risk stratification and post-operative expectations.

Reduction in Standard Cancer Screening in 2020 throughout the U.S.

Cancer screening is an important way to reduce the burden of cancer. The COVID-19 pandemic created delays in screening with the potential to increase cancer disparities in the United States (U.S.). Data from the 2014-2020 Behavioral Risk Factor Surveillance System (BRFSS) survey were analyzed to estimate the percentages of adults who reported cancer screening in the last 12 months consistent with the U.S. Preventive Services Task Force (USPSTF) recommendation for cervical (ages 21-65), breast (ages 50-74), and colorectal cancer (ages 50-75) prior to the pandemic. Cancer screening percentages for 2020 (April-December excluding January-March) were compared to screening percentages for 2014-2019 to begin to look at the impact of the COVID-19 pandemic. Screening percentages for 2020 were decreased from those for 2014-2019 including several underserved racial groups. Decreases in mammography and colonoscopy or sigmoidoscopy were higher among American Indian/Alaskan Natives, Hispanics, and multiracial participants, but decreases in pap test were also highest among Hispanics, Whites, Asians, and African-Americans/Blacks. Decreases in mammograms among women ages 40-49 were also seen. As the 2020 comparison is conservative, the 2021 decreases in cancer screening are expected to be much greater and are likely to increase cancer disparities substantially.

Measuring Changes in Perceptions of Access to Pet Support Care in Underserved Communities.

Understanding social, economic, and structural barriers to accessing pet care services is important for improving the health and welfare of companion animals in underserved communities in the U.S. From May 2018-December 2019, six questions from the validated One Health Community Assessment were used to measure perceptions of access to pet care in two urban and two rural zip codes. One urban and one rural community received services from a pet support outreach program (Pets for Life), while the other served as a comparison community. After propensity score matching was performed to eliminate demographic bias in the sample (Urban = 512 participants, Rural = 234 participants), Generalized Estimating Equations were employed to compare the six measures of access to pet care between the intervention and comparison communities. The urban community with the Pets for Life intervention was associated with a higher overall measure of access to pet care compared to the urban site that did not have the Pets for Life intervention. When assessing each of the six measures of access to care, the urban community with the Pets for Life intervention was associated with higher access to affordable pet care options and higher access to pet care service providers who offer payment options than the community without the Pets for Life intervention. Further analyses with a subset of Pets for Life clients comparing pre-intervention and post-intervention survey responses revealed statistically significant positive trends in perceptions of two of the six measures of access to pet care. This study provides evidence that community-based animal welfare programming has the potential to increase perceptions of access to pet support services.

Assessing Colorectal Cancer Screening Barriers in Rural Appalachia.

OBJECTIVES: The age-appropriate colorectal cancer (CRC) screening rate in the rural Appalachian area is low compared with the national rate, which may account for the overall higher incidence of CRC in this area. The purpose of this study was to explore potential barriers to CRC screening in the West Virginia Appalachian area. METHODS: A cross-sectional survey was designed to identify patient-reported barriers to CRC screening using the health belief model to assess their attitudes and behaviors. Autonomous paper-based surveys were randomly handed to individuals older than 50 years at various locations, including healthcare and nonhealthcare facilities. All of the responses were then categorized into two groups: the screened group and the unscreened group. Differences among both groups were statistically analyzed. RESULTS: There were three main areas that significantly accounted for the discrepancies between the screened and unscreened groups: perceptions of discomfort from screening tests, psychological and behavior deterrents in CRC screening and diagnosis, and limited resources for accessing care, especially transportation. In particular, psychological and behavioral deterrents in CRC screening appeared to play a role in promoting aversion to CRC screening. CONCLUSIONS: Lack of CRC screening awareness and knowledge may be responsible for fatalism regarding CRC and aversion to screening. Thus, multidisciplinary interventions that provide education about CRC screening, early intervention prognosis, and treatment options, as well as addressing systemic barriers to screening, such as assistance with scheduling, prep instructions, and transportation, can improve the screening rate in Appalachia and eventually lead to better outcomes through the early diagnosis of CRC.

Survival after Margin-Positive Resection in the Era of Modern Chemotherapy for Pancreatic Cancer: Do Patients Still Benefit?

BACKGROUND: R0 resection for pancreatic cancer is considered standard of care, but is not always achieved. This study looks at R1/R2 resection outcomes compared with chemotherapy alone. Our hypothesis is that patients with margin-positive disease have better outcomes than those receiving chemotherapy alone. STUDY DESIGN: Stage II pancreatic cancer patients who underwent R1/R2 surgery with/without neoadjuvant chemotherapy, from the National Cancer Database (NCDB) 2010 to 2017 were identified and compared with similar staged patients who received chemotherapy alone. The surgical group was then analyzed by subset based on receipt of chemotherapy: upfront surgery (+/- adjuvant therapy) and neoadjuvant therapy followed by surgery (+/- adjuvant therapy). RESULTS: There were 11,699 Stage II pancreatic cancer patients included, 9,521 (81.4%) of whom were treated with chemotherapy alone, 15.7% (n = 1,836) had upfront surgery, and 2.9% (n = 342) had neoadjuvant therapy with surgery. R1/R2 neoadjuvant patients had the best overall survival at a mean of 19.75 months (95% CI 17.91, 22.28) compared with the upfront surgery group (17.77 months, 95% CI 15.64, 19.55) and the chemotherapy alone group (10.12 months, 95% CI 8.97, 11.50) (hazard ratio [HR] 0.46 upfront surgery and 0.32 neoadjuvant group, respectively, p < 0.0001). Even with R2 resection, survival was better in surgical patients compared with patients who underwent chemotherapy only (15.76 mo vs 10.22 mo, p = 0.06). Patients with R1/R2 resections had improved survival if they received neoadjuvant/adjuvant chemotherapy, though the survival rates were significantly lower than those with standard R0 resections (n = 16,129). CONCLUSIONS: R1 resection has benefit over chemotherapy alone in pancreatic cancer. Pancreatic cancer patients who are left with microscopic R1 disease have better survival than without surgery, particularly in the setting of neoadjuvant therapy.

Outcomes with Preoperative Biliary Stenting After Pancreaticoduodenectomy In the Modern Era.

BACKGROUND: Previous studies have documented increased complications following pancreaticoduodenectomy in patients who undergo preoperative biliary stenting (PBS). However, in the modern era, the vast majority of patients with jaundice are stented. We hypothesized that there is no difference in short-term postoperative outcomes between PBS and no PBS in patient with obstructive jaundice undergoing pancreaticoduodenectomy. METHODS: We performed an analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) participant use file (2014-2017). Patients who received neoadjuvant chemotherapy and required stenting were excluded from the analysis. A propensity-matched analysis was performed to select obstructive jaundice patients who underwent PBS and those who did not with similar characteristics prior to pancreaticoduodenectomy. Short-term postoperative outcome measures included superficial surgical site infection (S-SSI), deep surgical site infection (D-SSI), hospital length of stay (LOS), postoperative pancreatic fistula (POF), hospital readmission, minor morbidity (Clavien-Dindo I-II), major morbidity (Clavien-Dindo III, IV, V), and 30-day mortality. RESULTS: A total of 5851 patients with obstructive jaundice underwent pancreaticoduodenectomy without neoadjuvant chemotherapy. 81.6% underwent PBS. Based on the propensity-matched analysis, 927 patients who received PBS and 927 patients who did not were selected for comparing the outcomes between the two groups. There was no significant difference in outcome measures between the two groups with respect to S-SSI (OR 1.30 , 95% CI = 0.94-1.80, p = 0.12), D-SSI (OR 1.07, 95% CI = 0.81-1.41, p = 0.62), POF (OR 1.11, 95% CI = 0.87-1.42, p = 0.40), hospital readmission (OR 0.99, 95% CI = 0.77-1.27, p = 0.94), minor morbidity (OR 0.91, 95% CI = 0.76-1.11, p = 0.36), major morbidity (OR 0.84, 95% CI = 0.67-1.06, p = 0.14), and 30-day mortality (OR 1.05, 95% CI = 0.57-1.95, p = 0.87). Patients who underwent PBS were more likely to have shorter LOS (RR 0.87, 95% CI = 0.81-0.93, p < 0.0001). CONCLUSION: Contrary to previously reported studies, there was no increased risk of short-term postoperative outcomes after pancreaticoduodenectomy between PBS and N-PBS in a propensity-matched analysis. Preoperative biliary stenting is safe and does not need to be avoided before surgical intervention in patients who present with obstructive jaundice.

Significance of Lymph Node Resection After Neoadjuvant Therapy in Pancreatic, Gastric, and Rectal Cancers.

OBJECTIVE: Gastrointestinal cancers are increasingly being treated with NAT before surgical resection. Currently, quality metrics are linked to the number of LNs resected to determine subsequent treatment and prognosis. We hypothesize that NAT decreases LN metastasis, downstages patients, and decreases overall lymph node yields (LNY) compared to initial surgical resection. With increasing use of NAT, this brings into question the validity of quality metrics. METHODS: Gastric (stage II/III), pancreatic (stage I/II/III), and rectal cancers (stage II/III) (2010-2015) treated with surgery with/without NAT were identified in National Cancer Database. We evaluated total LNY and LN metastasis with/without NAT and clinical and pathological stage to evaluate rates of downstaging. RESULTS: A total of 7934 gastric, 15,908 pancreatic, and 21,354 rectal cancer patients were included of which 61.1%, 21.2%, and 85.7% received NAT, respectively. NAT patients were more likely to be downstaged (39.9% vs 11.1% gastric P< 0.001, 30.6% vs 3.2% pancreatic P< 0.001, 52.0% vs 16.3% rectal P< 0.001), have lower LNYs (18.8 vs 19.1 gastric P = 0.239, 18.4 vs 17.5 pancreatic P< 0.001, 15.7 vs 20.0 rectal P< 0.001) and have N0 pathologic disease (43.6% vs 26.7% gastric P< 0.001, 51.1% vs 30.9% pancreatic P< 0.001, 65.9% vs 49.4% rectal P< 0.001) when compared to initial surgical resection. CONCLUSION: NAT for gastrointestinal cancers results in overall lower LN yields, lower LN metastases, and significant downstaging of tumors. As all patients undergoing NAT receive multimodality therapy, LN yield recommendations may not be true quality metric changing.

Surgical job negotiations: How current literature and expert opinion can inform your strategies.

BACKGROUND: Negotiation is an essential professional skill. Surgeons negotiating new roles must consider: 1) career level (e.g., new graduate, mid-career or leadership), 2) practice environment (e.g., academic, private practice), 3) organization (e.g., academic, university-affiliated, specialized center), and 4) work-life needs (e.g., geography, joint recruitment). METHODS: A review of the literature related to surgical job negotiation was conducted. Expert opinion was also sought. RESULTS: Current data and experience suggest that negotiation must be tailored to practice type, surgeon experience/skill set and should always occur with the advice of legal counsel. Understanding principled negotiation and engaging in preparation and practice will also improve negotiation skills. CONCLUSIONS: Our findings shed light on common blind spots among surgeons negotiating new professional roles and provide guidance on optimizing job negotiation skills.

Are We Making an Impact? A Qualitative Program Assessment of the Resident Leadership, Well-being, and Resiliency Program for General Surgery Residents.

OBJECTIVE: After implementing a formal resident well-being and resiliency program in our surgery residency, we performed in-depth qualitative interviews to understand residents' perceptions of: (1) the impact and benefits, (2) the essential elements for success, and (3) the desired changes to the well-being program. DESIGN: The well-being program is structured to address mental, physical, and social aspects of resident well-being through monthly experiential sessions. All General Surgery residents participated in the program; content is delivered during residents' protected educational time. For this study, we conducted individual semistructured interviews: residents were asked for their feedback to understand the value, benefits, and drawbacks of program. SETTING: Accreditation Council for Graduate Medical Education-accredited General Surgery residency program PARTICIPANTS: We used purposeful selection to maximize diversity in recruiting residents who had participated in program for at least 1 year. Recruitment continued until themes were saturated. Eleven residents were interviewed including 2 from each residency year. RESULTS: Residents reported benefits in 3 thematic spheres: (1) Culture/Community, (2) Communication/Emotional Intelligence, and (3) Work-Life Integration Skills. Key structural elements of success for a well-being program included a committed leader, a receptive department culture, occurrence during protected time, and interactive sessions that taught applicable life skills. In discussing opportunities for improvement, residents desired more faculty-level involvement. Some residents were skeptical of the benefit of time spent learning nontechnical skills; some wanted more emphasis placed on accountability to patients and work. CONCLUSIONS: Our qualitative assessment of a novel resident well-being program demonstrates reported benefits that reflect the intent of the program. Residents most benefited from sessions that were interactive, introduced readily applicable skills for their day-to-day lives, and included reinforcement of principles through experiential learning. Engagement of the department leadership is essential to the success of the program, as is ongoing feedback and modification to ensure that program is tailored to the needs of residents.

Incidental Cancer Diagnoses in Trauma Patients: A Case-Control Study Evaluating Long-term Outcomes.

BACKGROUND: This study evaluates whether trauma patients who incidentally learned about a malignancy have similar long-term outcomes as patients who organically learned about their malignancy. MATERIALS AND METHODS: Incidental findings (IF) patients were matched to noninjured cancer controls on age group, sex, cancer site, stage, and year of diagnosis. Unadjusted covariates included race, insurance type, rural residence, and time from diagnosis to first cancer intervention. Cox proportional hazard regression models were used to measure adjusted all-cause and cancer-specific mortality risk. RESULTS: Adjusted long-term mortality risk among IF cases was 1.42 (95% confidence interval [1.11-1.81]) compared with noninjured cancer controls. There was no statistically significant difference in all-cause mortality among IF cases who survived at least 30 d (1.24 [0.88-1.74]). IF cases had no increased risk of cancer-related mortality compared with controls (1.26 [0.96-1.64]). CONCLUSIONS: Long-term mortality risks among trauma patients with incidental cancer diagnoses are no different than the cancer population as a whole among patients who survive at least 30 d after injury. IF trauma patients are not more susceptible to cancer-related causes of death as a result of a physiological stress response due to injury.

Pancreatic Cancer Lymph Node Resection Revisited: A Novel Calculation of Number of Lymph Nodes Required.

BACKGROUND: Pancreatic cancer is the third leading cause of cancer related deaths in the US. Although lymph node (LN) metastasis is a prognostic indicator, the extent of LN resection is still debated. Our goal was to use the distribution of the ratio of positive to negative LNs to derive a more adequate number of necessary examined LNs based on the target LN threshold (TLNT). STUDY DESIGN: Using the National Cancer Database, we performed a retrospective study of surgically resected pancreatic adenocarcinoma (2010 to 2015). We evaluated the number of positive LNs and total LNs examined and the log of the ratio of positive LNs to negative LNs (LODDS). The distribution of LODDS was examined to determine a target LNs examined threshold sufficient to detect N1 disease. Using the LODDS distribution of N1 cases, target LNs examined threshold were calculated to encompass 90 of the N1 group distribution. RESULTS: Of the total 24,038 resected patients included in this study, 26% underwent operation only, 18% received neoadjuvant therapy, and 56% underwent adjuvant therapy. In all, 8,144 (34%) patients had N0 disease and 15,894 (66%) had N1 disease. To capture 90% to 95% of the N1 group, the minimum number of LNs examined would be 18 (LODDS -2.74) to 24 (LODDS -3.04), respectively. CONCLUSIONS: Although previous studies have suggested 11 to 17 LNs required for adequate LN sampling in pancreatic cancer, our findings suggest that to capture 90% of cases with N1 disease, 18 LNs is more appropriate.

Later Stage Disease and Earlier Onset of Rectal Cancer: Epidemiology and Outcomes Comparison of Rectal Cancer in a Rural Appalachian Area to State and National Rates.

Although the overall rate of colorectal cancer (CRC) has remained stable, studies have shown an increase in the rate of CRC in young patients (<50) nationwide. We hypothesize that the rectal cancer (RC) rate in young people has increased in rural Appalachia. The goal is to provide insight into the future of RC epidemiology in underserved populations. This Institutional Review Board-approved retrospective study evaluated RC patients diagnosed in 2003 to 2016, and compared the ratio of early-onset RC to the state and national ratios using West Virginia State Cancer Registry, North American Association of Central Cancer Registries (NAACCR) and Surveillance, Epidemiology, and End Results Program Database. Demographics include age, gender, ethnicity, and county. We also evaluated cancer stage, family history, and comorbidities, including body mass index, smoking, and alcohol history. The rate of early-onset RC in our area is 1.5 times higher than the national rates. In our population, 100 per cent of patients were white with an equal gender distribution. Young patients with RC were noted to be more overweight than national rates. Young RC patients are more likely to have a first- or second-degree relative with cancer diagnosis. Smoking was strongly associated with young RC. Compared with national statistics, a higher proportion of young patients had Stage 1 or 2 disease which correlated with better survival. The rate of early-onset RC in the Tristate Appalachian area in West Virginia is higher than the national rate with risk factors including white ethnicity, obesity, diabetes mellitus, smoking, family history, and history of pelvic surgeries. It warrants further investigation and discussion of current CRC screening guidelines that begin at age 50.

Greening the operating room.

BACKGROUND: Climate change will affect most populations in the next decades and put the health of billions of people at risk. Health care facilities represent a significant source of pollution around the world and contribute to environmental changes. To address this topic, we performed a review of the available literature on tactics to reduce operating room (OR) waste and the potential of these strategies to impact the environment. DATA SOURCES: A literature search was performed querying PubMed, Web of Science, and Science Direct. No comparative data were found; most were opinion papers, white papers, and case studies. For this reason, we proceeded with a narrative review, which provides an overview of the evidence on this topic and identifies areas for future research. RESULTS: This systematic review summarizes the available literature on the 5 "Rs" of waste management: reduction, reusing, recycling, rethinking, and renewable energies. CONCLUSIONS: Surgery has a unique opportunity to transition to more environmentally-friendly operating room strategies, which may help decrease waste and lessen the impact of climate change.