Journal of Visceral Surgery最新文献

Healthcare sectors, particularly operating theaters, are major consumers of resources. Given today's climate-related issues, its seems vital that the different healthcare professionals in operating areas become aware of their roles. This is pronouncedly the case for hospital pharmacists, who fulfill cross-sectional functions in the proper use and management of healthcare products and sterile medical devices. The objective of this review of the literature is to identify the actions a hospital pharmacist can take to impel evolution toward ecologically responsible care in the operating theater. Seven areas in which a pharmacist can assume a leading, supporting or composite role in rendering an operating theater ecologically responsible have been highlighted: purchasing, procurement and storage, harmonization of practices, modification of practices, professional attire, waste elimination and research/teaching. The active participation of all healthcare professionals, including the hospital pharmacist, is essential to the development of a sustainable approach to healthcare.

Introduction

Above and beyond the environmentally responsible operating theater, the environmental impact of the pathways of surgically treated patients seems essential but has seldom been considered in the literature. On a parallel track, enhanced recovery programmes (ERP) programs are presently deemed a standard of care. The objective of this review is to determine the carbon footprint of the ERP approach in colorectal surgery.

Method

This a narrative review based on articles referenced in PubMed. Our search was centered on the environmental impact of an ERP in the context of colorectal surgery. A number of measures included in the national and international guidelines were studied. We utilized the terms “carbon footprint”, “sustainability”, “energy cost”, “environmental footprint”, “life cycle assessment” AND a key word for each subject found in the ERP recommendations.

Results

Most ERP measures in the context of colorectal surgery are factually or intuitively virtuous from an ecological standpoint. With a 3-day reduction in average hospital stay resulting from ERP, the program permits a reduction of at least 375 kg CO₂e/patient (Appendices 1 and 2). The most substantial part of this reduction is achieved during the perioperative period. While some measures, such as short fasting, are ecologically neutral, others (treatment of comorbidities, smoking cessation, hypothermia prevention, antibiotic prophylaxis, laparoscopy, absence of drains or probes, thromboprophylaxis, early feeding and mobilization…) lead to fewer postoperative complications, and can consequently be considered as environmentally responsible. Conversely, other measures, one example being robotic surgery, leave a substantial carbon footprint.

Conclusion

ERP is congruent with two pillars of sustainable development: the social pillar (improved patient recovery, and better caregiver working conditions fostered by team spirit), and the economic pillar (decreased healthcare expenses). While the third, environmental pillar is intuitively present, the low number of published studies remains a limitation to be overcome in future qualitative studies.

Following a reminder on the quantities of carbon emitted in the healthcare sector, and casting a spotlight on those directly related to architecture, the authors of this article will develop three large-scale themes, the objective being to render hospital construction sustainable. 1. Energy consumption and how to reduce it. 2. “Low-carbon” construction and how building designers can limit emissions by the choice of construction materials. 3. The “resilience” of some constructions, their capacity to stave off obsolescence. As a conclusion, the authors present one of the most recent projects of the Brunet Saunier & Associates architecture agency: the Saint-Ouen university hospital, Grand Paris Nord. This project is illustrative of these preoccupations and demonstrates the possibility of meeting the challenges of sustainable development by means of simple and durable architecture.

Aim

Digestive stoma are frequently performed. The last French guidelines have been published twenty years ago. Our aim was to update French clinical practice guidelines for the perioperative management of digestive stoma and stoma-related complications.

Methods

A systematic literature review of French and English articles published between January 2000 and May 2022 was performed. Only digestive stoma for fecal evacuation in adults were considered. Stoma in children, urinary stoma, digestive stoma for enteral nutrition, and rare stoma (Koch, perineal) were not included.

Results

Guidelines include the surgical landmarks to create digestive stoma (ideal location, mucocutaneous anastomosis, utility of support rods, use of prophylactic mesh), the perioperative clinical practice guidelines (patient education, preoperative ostomy site marking, postoperative equipment, prescriptions, and follow-up), the management of early stoma-related complications (difficulties for nursing, high output, stoma necrosis, retraction, abscess and peristomal skin complications), and the management of late stoma-related complications (stoma prolapse, parastomal hernia, stoma stenosis, late stoma retraction). A level of evidence was assigned to each statement.

Conclusion

These guidelines will be very useful in clinical practice, and allow to delete some outdated dogma.

Aim of the study

In histologically non-inflamed but clinically suspect appendices, changes described as neurogenic appendicopathy with fibrous or fibrolipomatous obliterations can be observed. The purpose of this study was to analyse the incidence of these entities of the appendix in a longitudinal patient cohort.

Patients and methods

This is a retrospective single-centre study of 457 patients undergoing laparoscopic appendectomy from 2017 to 2020 due to suspected acute appendicitis.

Results

In 72 patients (15.8%) with clinically suspected acute appendicitis, the appendix showed no distinct signs of acute inflammation during the procedure. In 43 patients, histological analysis revealed neurogenic appendicopathy or fibrous and fibrolipomatous obliteration. Female gender (P = 0.088), younger age (P < 0.0001), longer pain duration (P < 0.0001) and repetitive pain episodes were more frequent in these patients than in those with acute appendicitis. Inflammation markers were also decreased in the group of patients with neurogenic appendicopathy (leukocytes 9.8 ± 3.5 vs. 13.0 ± 4.5 G/L and C-reactive protein 38.7 ± 60.7 vs. 59.4 ± 70.5 mg/L).

Conclusion

Neurogenic appendicopathy with fibrous/fibrolipomatous obliteration is a differential diagnosis of acute appendicitis that can only be confirmed by pathology. Female gender, young age, prolonged duration with repetitive episodes of pain, and relatively low inflammatory markers are evocative of this diagnosis.

Gastric band migration, for which abscess of the subcutaneous port is an alarm signal, can in some cases be asymptomatic. Therapeutic options for withdrawal of the migrated band include colonoscopy (if the band is located at the level of the ileo-caecal valve), laparoscopy and mini-laparotomy.

Introduction

The histological examination (HE) of all cholecystectomy specimens removed for cholelithiasis is a widespread practice to rule out unrecognized gallbladder cancer. (GBC). But this dogmatic practice has been called into question by recent published data. The aim of this literature review was to answer two questions: (1) can HE be omitted in specific cases; (2) under what conditions is a selective strategy indicated?

Methods

A review of the literature was carried out that included selected multicenter studies, registry studies, or meta-analyses. A reliable technique for the surgeon's macroscopic examination of the specimen would allow the selection of dubious cases for HE. The cost-effectiveness of selective HE was discussed. The PICO methodology (population, intervention, comparator, outcome) was used in the selection of articles that compared routine and selective histological examination.

Results

If cases from countries with a high prevalence of gallbladder cancer are excluded and in the absence of high-risk situations (advanced age, female gender, calcified or porcelain gallbladder, acute cholecystitis, polyps, abnormalities noted intra-operatively), the macroscopic examination of the gallbladder in the operating room has a reliability approaching 100% in the majority of published studies. This would make it possible to omit systematic HE without compromising the diagnosis and prognosis of patients with unsuspected GBC and with a very favorable cost-effectiveness ratio.

Conclusion

Through a selection of patients at very low risk of incidentally-discovered cancer and a routine macroscopic examination of the opened gallbladder, the strategy of selective HE could prove useful in both clinical and economic terms.