BMJ Surgery Interventions Health Technologies最新文献

Abstract:

Background: In France, 25% of healthcare emissions are attributed to the supply of medical devices, underscoring the necessity for the development of more sustainable procurement policies. However, comparing the carbon footprint of different devices, especially single-use devices versus reusable ones, presents challenges.

Objective: To assess the carbon footprint of single-use and reusable electrosurgical scalpels over 1 year of use in our hospital setting.

Design: A cradle-to-grave analysis was conducted from May 1, 2022, to April 30, 2023.

Setting: Nantes University Hospital, France.

Main outcome measures: The study quantifies carbon emissions across all life cycle stages: raw material extraction, manufacturing, transportation, use, maintenance, and disposal. For reusable devices, sterilization emissions were allocated based on the total annual workload of the Central Sterile Services Department. Carbon footprint values were derived from direct measurements, manufacturer and supplier data, and literature, with conversions using a public and national database (Base Empreinte, ADEME).

Results: The carbon footprint of single-use devices was estimated at 4291 kg of carbon dioxide equivalent (CO₂e), with 94% attributed to the production of the device itself. The carbon footprint related to the reusable device was estimated at 494 kg CO₂e, with 86% stemming from handling at our sterilization unit.

Conclusions: These findings are contingent on our hospital's practices and may vary based on several factors. Beyond estimating these carbon footprints, it provides a practical, decision-oriented analysis accessible for hospital leadership and healthcare professionals, supporting institutional change.

Objectives: To determine whether neural network models based on electronic health record (EHR) data can match and augment the performance of models based on clinical registry data in predicting readmission after peripheral vascular intervention (PVI).

Design: Observational cohort study.

Setting: Vascular Quality Initiative registry and INSIGHT Clinical Research Network EHR data from multiple academic institutions in New York City.

Participants: Patients undergoing PVI during January 1, 2013 to September 30, 2021.

Main outcome measures: Our outcome variable was 90-day readmission. We developed logistic regression (LR), multilevel perceptron (MLP), and recurrent neural network (RNN) models using registry alone, EHR data alone, and combined registry-EHR data. EHR data were evaluated using derived variables to match registry variables (EHR-derived data) and clinically meaningful code aggregation (EHR-direct data). Models were evaluated using area under the curve (AUC) for discrimination, Spiegelhalter z score for calibration, and Brier score for overall performance.

Results: The analytical cohort included 2348 patients undergoing PVI (mean age: 69.9±11.5 years). 832 (35%) patients were readmitted within 90 days. LR to predict 90-day readmission based on registry data alone had an AUC of 0.710, Spiegelhalter z score of 1.021, and Brier score of 0.211. MLP based on registry data alone had similar performance. MLP and RNN based on EHR-direct data (MLP: AUC=0.742, Spiegelhalter z=0.933, Brier=0.204; RNN: AUC=0.737, Spiegelhalter z=1.026, Brier=0.206) and registry+EHR-direct data (MLP: AUC=0.756, Spiegelhalter z=0.794, Brier=0.199; RNN: AUC=0.751, Spiegelhalter z=1.057, Brier=0.200) had improved performances. LR based on EHR-direct data and combined registry+EHR-direct data had worse performances.

Conclusions: EHR data, when used with neural network models, can be useful to establish readmission predictive models or augment clinical registry data. EHR-based models can be potentially embedded in the clinical workflow, but model performance may be constrained by the absence of certain information in clinical encounters, such as social determinants of health.

Objectives: This study aimed to use indocyanine green (ICG) fluorescence-guided knee arthroscopy to observe the meniscus and surrounding tissue vascularity and determine correlation with the patients' backgrounds. Currently, no data are available on the clinical application of ICG fluorescence-guided knee arthroscopy in assessing meniscal vascularity.

Design: Prospective, case series.

Setting: In-hospital settings.

Participants: 41 knees of 34 patients were examined. 4 knees of 4 patients were included in a pilot study for technique refinement only, while the remaining 37 knees of 30 patients were included in the study.

Main outcome measures: The times from ICG administration to fluorescence onset and fluorescence duration from onset to complete attenuation were recorded. The fluorescence intensity at the anterior, middle, and posterior segments of the meniscus was evaluated on a 4-point scale. The younger and older and smoker and non-smoker groups were compared.

Results: The average fluorescence onset time was 32.05 s, whereas the average fluorescence duration was 11 min 14 s. The age groups aged≤45 and ≥46 years showed an onset of 30±24.9 and 33.17±16.2 s and a duration of 12 min 54 s and 10 min 20 s, respectively. The smoking and non-smoking groups exhibited an onset of 28.33±14.4 and 33.84±21.5 s and a duration of 10 min 37 s and 11 min 32 s, respectively. All segments of the lateral meniscus showed higher fluorescence intensities than the medial. The posterior segment of the lateral meniscus at ≤45 was markedly more fluorescent and significantly different from ≥46.

Conclusions: Fluorescence was observed for approximately 30 s after intravenous ICG injection and lasted approximately 10 min. Fluorescence intensity was brighter in the posterior segment of the lateral meniscus, particularly at ≤45. ICG fluorescence-guided knee arthroscopy may assist in case-specific hemodynamics and real-time surgical evaluation of the meniscus in living humans.

[This corrects the article DOI: 10.1136/bmjsit-2024-000304.].

Objectives: Post-pancreatectomy acute pancreatitis (PPAP) has been a well-defined entity by the International Study Group of Pancreatic Surgery. Underlying cause may be hypoperfusion at remnant stump of pancreas, which has been linked with additional post-pancreatectomy complications like postoperative pancreatic fistula. The primary goal was to assess the vascularity of remnant pancreas utilizing indocyanine green with near-infrared fluorescence. Indocyanine Green could aid in objectively mitigating hypoperfusion status of the pancreatic stump.

Design: Hospital-based descriptive study conducted as per the revised Strengthening the Reporting of Observational Studies in Epidemiology guidelines between 1 August 2022 and 2 August 2023.

Setting: This study was conducted in tertiary care centers of Kathmandu.

Participants: All 43 participants who underwent pancreaticoduodenectomies were included who completed the study.

Intervention: Blood supply to the remnant of the pancreas during pancreaticoduodenectomy was assessed utilizing indocyanine green, capturing distinct arterial, venous, and port venous phases, which were analyzed after 10 to 15 s of administration.

Main outcome measures: In three instances, indocyanine green dye revealed unequal vascular supply at the pancreatic remnant, requiring adjustments to the margins before completing the anastomosis of the remnant pancreas and the jejunum.

Results: PPAP was noticed in eight patients (18.6%), among which five patients (11.6 %) had postoperative hyperamylasemia, and three had grade B PPAP. The outcomes revealed that in the 40 patients with adequate perfusion, PPAP occurred in seven patients(16.3%), and grade B clinically relevant postoperative pancreatic fistula occurred in one patient. In contrast, among the three patients with inadequate perfusion, after revision of the pancreatic margin, PPAP was observed in one patient, and none of them had clinically relevant post-operative pancreatic fistula.

Conclusion: Postoperative acute pancreatitis, ultimately exhibiting the possibility of postoperative pancreatic fistula, must be monitored with vigilance. While several elements contribute to fistula formation, ensuring sufficient vascular supply at the pancreatic remnant using indocyanine green may alleviate presumed PPAP and associated complications. The dye could aid in enhancing surgical outcomes following pancreaticoduodenectomy.

Objectives: A recent meta-analysis of high-quality randomized trials casts doubt on the effectiveness of triclosan-coated sutures in reducing surgical site infection (SSI). This economic analysis is aimed at assessing whether triclosan-coated sutures, compared with uncoated sutures, can reduce costs from a healthcare perspective.

Design: This was a model-based economic analysis mainly informed by baseline SSI rates, effect size CIs from a recent meta-analysis of high-quality trials (OR 0.90, 95% CI 0.74 to 1.09, p=0.29), and country-specific cost data.

Setting: This was a worldwide analysis that estimated average cost savings aggregated for high, middle, and low Human Development Index (HDI) countries and country-specific cost savings for the 193 countries on the HDI list.

Participants: Participants were patients undergoing abdominal surgery. The analysis was informed by baseline SSI rates from an international cohort study (12 539 patients).

Main outcome measures: Results are reported in 2022 US dollars as average cost differences associated with SSI between coated and uncoated sutures. Deterministic sensitivity analyses examined variations in suture cost, hospital stay costs, and effect size, with best and worst-case scenario analyses.

Results: SSI-related cost differences per patient ranged from -$466 to $171 in high-HDI, -$23 to $18 in middle-HDI, and -$34 to $22 in low-HDI countries when triclosan-coated sutures were used. The largest potential savings and expenditure occurred in contaminated-dirty wounds. Similar results were observed at the national level in 184 of 193 countries. Best-case to worst-case analyses showed a range of -$533 to $192 in high-HDI, -$57 to $49 in middle-HDI and -$69 to $52 in low-HDI countries.

Conclusions: This analysis highlights significant uncertainty regarding cost savings with routine use of triclosan-coated sutures, emphasizing the need for high-quality data and CI-based economic analysis in policy making.

Objectives: Evaluate the effectiveness of indocyanine green (ICG) fluorescence in enhancing the safety and precision of biliary anastomosis during liver transplantation (LT). The primary research question was whether ICG could provide real-time, objective assessment of bile duct vascularization to reduce postoperative biliary complications.

Design: Prospective, observational case series. IDEAL Stage 1 study.

Setting: Tertiary care academic medical center in Barcelona, Spain.

Participants: 10 adult patients who underwent LT between January 2023 and July 2024. Patients were selected based on the indication for LT with varying etiologies of liver failure. Donors included those with brain death and circulatory death (DCD).

Interventions: ICG was administered intravenously as a 3 mg bolus dose to evaluate the vascularization of the bile duct stumps. Fluorescence was visualized using a high-definition camera system during surgery, and adjustments to the anastomosis site were made based on the fluorescence patterns observed.

Main outcome measures: The primary outcome was the identification of non-vascularized (non-fluorescent) bile duct tissue and subsequent adjustments to the anastomosis site. Secondary outcomes included the incidence of biliary complications and patient survival during the follow-up period.

Results: ICG fluorescence successfully identified non-fluorescent areas in the bile duct stumps, leading to surgical adjustments in five cases (50%), particularly in DCD grafts. The procedure was well-tolerated with no adverse events related to ICG administration. The use of ICG fluorescence added an average of 3-5 min to the operative time. No biliary complications were reported during follow-up, and patient survival was 100%.

Conclusions: ICG fluorescence provides a valuable, objective tool for assessing bile duct vascularization during LT, potentially reducing biliary complications. This technique's integration into clinical practice could enhance surgical precision and improve patient outcomes. Further research is needed to confirm these findings in larger, more diverse populations.

Abstract:

Objectives: The primary objective of this study was to investigate perioperative factors associated with symptom-to-surgery (STS) time in patients diagnosed with hyper-acute aortic dissection (AAD). The secondary objective was to develop a causal model to understand the relationship between STS times and hospital mortality in this population.

Design: Prospective cohort study.

Setting: Exploratory analysis of a national audit conducted by the Association of Cardiothoracic Anaesthesia and Critical Care.

Participants: From a total of 270 participants diagnosed with AAD with an STS time <72 hours, 218 were included in the multivariate analysis, after excluding 52 participants with missing covariates.

Main outcome measures: STS time, measured in hours. Hospital mortality at 30 days.

Results: In the multivariate analysis, mean STS time for misdiagnosed patients was nearly twice as high when compared with patients who initially had the correct diagnosis (estimated proportion of change=1.9, 95% CI 1.5 to 2.3, p<0.001). STS time decreased when patients were accompanied by a medical doctor in the ambulance transfer, had mean arterial blood pressure below 70 mm Hg or presented to the emergency department (ED) with a Glasgow Coma Scale (GCS) <15. Estimated ED-to-surgery (ETS) times were 1.8 hours longer for women than for men (10.5 hours, 95% CI 9.0 to 12.0 hours vs 8.7 hours, 95% CI 7.8 to 9.6 hours). From a total of 334 patients, 64 (19.2%) died. Mortality was higher in older patients and when STS time was ≥6 and <24 hours, compared with STS time <6 hours.

Conclusions: Potentially modifiable factors that may reduce STS times include avoidance of misdiagnosis and provision of a medical doctor for the ambulance transfer. Younger women had longer STS and ETS times, but further research is warranted to investigate the impact of age and sex on these times. The relationship between STS time and hospital mortality among these patients remains unclear.

Objectives: Stenting is a method of controlling airway occlusions (CAO) that can be used alone or in combination with other treatments. There are different types of airway stents. One of the most widely used types is silicone stent. These stents are flexible and firm enough cylinders inserted into the airway by a rigid scope to relieve dyspnoea caused by CAO in malignant and non-malignant diseases. We have developed a method that can be applied quickly in remote urgent cases without a rigid scope.

Design: We used two endotracheal tubes with a size of 8.5 for stenting.

Setting: This research was conducted at Pediatric Urology and Regenerative Medicine Research Center, Children's Medical Center, Pediatric Center of Excellence, Animal Lab Tehran University of Medical Sciences, Tehran, Iran (IR).

Participants instead of patients or subjects: Two certified mature sheep (ewes).

Interventions: Silicone stent placement for 2 months.

Main outcome measures: A method with minimal facilities for stenting without limitation of trachea size.

Results: A pilot animal study has been performed on two mature certified sheep to test a stenting procedure. Stenting procedures have been successfully implemented on the animals' trachea.

Conclusions: We have developed a new simple, fast and cheap procedure for stenting silicon stents with minimum risk. We can easily place and rotate the stent during the procedure.