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.

Revising a laparoscopic appendicectomy set to reduce reliance on disposable surgical instruments: supporting the transition to sustainable surgical practice.

INTRODUCTION: After excluding anaesthetic gases, around one-third of carbon emissions from surgical procedures are from consumables. This sustainable quality improvement project revised the laparoscopic appendicectomy surgical set at a large teaching hospital, with the aim of reducing unnecessary usage of disposable laparoscopic ports and surgical instruments. METHODS: A prospective audit of 25 consecutive laparoscopic appendicectomies (5% of annual appendicectomies performed at the Trust) was conducted to assess use of disposable instruments. The financial and environmental costs of the five most commonly used disposable instruments were calculated and annual cost of current practice determined. A revised surgical set was created to include additional reusable instruments and new reusable ports. A reaudit of disposable surgical instrument usage was conducted and the financial and environmental impact of the new set compared with the results from the initial audit. RESULTS: A total of 109 disposable instruments were opened in 25 appendicectomies, costing an estimated £49,656 and 692kg CO2 equivalent (CO2e) annually. Following rollout of the revised appendicectomy set, there was a significant reduction in disposable instrument usage (median four versus one instruments per case, p<0.00001). The revised set is predicted to reduce annual disposable instrument usage from 2,180 to 705 instruments (68% reduction), saving £219,452 and 3.02 tonnes CO2e over the estimated seven-year lifecycle of the reusable instruments. CONCLUSIONS: Updating a laparoscopic appendicectomy set to include additional/new reusable instruments can lead to a marked reduction in disposable surgical instrument usage. This results in significant projected financial and CO2e savings.

Colorectal cancer outcomes determined by mode of presentation: analysis of population data in England between 2010 and 2014.

BACKGROUND: The purpose of this study was to investigate associations between mode of presentation; categorized as emergency, suspected cancer outpatient referral pathway (2-week wait or 2WW pathway), non-cancer suspected outpatient referral (non-2-week wait pathway) or following screening, and stage of diagnosis and survival in patients with colorectal cancer in England. METHODS: This was a retrospective cohort observational study of patients diagnosed with colorectal cancer between January 2010 and December 2014 in England using data from Public Health England collated from regional cancer registries. RESULTS: The most common route to diagnosis among 167,501 patients diagnosed with colorectal cancer was via the non-cancer suspect (non-2WW) outpatient referral pathway (35.1%) followed by the suspected cancer (2WW) referral pathway (31.6%), emergency presentation (22.8%) and most infrequently following screening (10.6%) (p < 0.01). Screening confers the greatest likelihood of early-stage diagnosis (61.6%) compared to other modes of presentation. The 5-year overall survival was 81.8%, 53.3%, 53.0% and 27.6% in those diagnosed via screening, 2WW, non-2WW pathway and emergency presentation, respectively. Patients from most deprived regions were more likely to be diagnosed following emergency presentation (27.7 vs 19.7%, p < 0.01) and less likely via screening (8.1 vs 12%, p < 0.01). CONCLUSIONS: Asymptomatic individuals diagnosed following screening have earlier stage cancers and better survival, the opposite was observed in those diagnosed following emergency presentation. Patients referred via the 2WW pathway do not have better survival outcomes when compared to those referred via the non-2WW pathway. In addition, this study has identified socio-economic groups that need to be targeted with public health campaigns to improve screening uptake.

5-Aminolevulinic acid for fluorescence-guided surgery in pancreatic cancer: Cellular transport and fluorescence quantification studies.

5-Aminolevulinic acid (ALA) is a potential contrast agent for fluorescence-guided surgery in pancreatic ductal adenocarcinoma (PDAC). However, factors influencing ALA uptake in PDAC have not been adequately assessed. We investigated ALA-induced porphyrin fluorescence in PDAC cell lines CFPAC-1 and PANC-1 and pancreatic ductal cell line H6c7 following incubation with 0.25-1.0 mM ALA for 4-48 h. Fluorescence was assessed qualitatively by microscopy and quantitatively by plate reader and flow cytometry. Haem biosynthesis enzymes and transporters were measured by quantitative polymerase chain reaction (qPCR). CFPAC-1 cells exhibited intense fluorescence under microscopy at low concentrations whereas PANC-1 cells and pancreatic ductal cell line H6c7 showed much lower fluorescence. Quantitative fluorescence studies demonstrated fluorescence saturation in the two PDAC cell lines at 0.5 mM ALA, whereas H6c7 cells showed increasing fluorescence with increasing ALA. Based on the PDAC:H6c7 fluorescence ratio studies, lower ALA concentrations provide better contrast between PDAC and benign pancreatic cells. Studies with qPCR showed upregulation of ALA influx transporter PEPT1 in CFPAC-1, whereas PANC-1 upregulated the efflux transporter ABCG2. We conclude that PEPT1 and ABCG2 expression may be key contributory factors for variability in ALA-induced fluorescence in PDAC.

Iatrogenic kwashiorkor after distal gastric bypass surgery: the consequences of receiving multinational treatment.

Protein-calorie malnutrition or kwashiorkor is extremely rare after gastric bypass surgery. We report a case of a woman referred to a weight management clinic in the United Kingdom who developed bilateral leg oedema 2 years after gastric bypass surgery in Tunisia. Her serum albumin concentration was 24 g/l, and her body mass index was 16.2 kg/m(2). A review of the postoperative report of her bariatric surgery revealed that she had undergone a distal bypass with anastomosis of the intestine at 1 m proximal to the ileocaecal valve. She required gastrostomy feeding for 6 months before undergoing revisional surgery to a proximal Roux-en-Y gastric bypass in order to restore healthy weight. We recommend that if patients are having their bariatric surgery outside of their country of residence, they should always obtain a copy of the operative notes so that these are readily available if complications arise.