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.

PSAT294 Black Thyroid – Is It a Benign or a Malignant Finding?: A Case Report and Review of the Literature

Background

Black thyroid is a rare condition with fewer than 70 cases reported around the globe. Black thyroid is seen almost exclusively in patients upon minocycline ingestion, and the process has previously been thought to be generally benign. Despite the favorable impact of this drug on thyroid function, several studies have reported an association between black thyroid and thyroid cancer. Herein, we report a black thyroid associated with papillary thyroid cancer.

Clinical Case

A 30-year-old woman with no significant medical history and no risk factors for thyroid cancer, but with a history of acne treated with minocycline for 2 months 10 years ago, came to the office for a thyroid nodule found during a routine healthcare visit. The patient was asymptomatic and euthyroid. Physical examination was unremarkable. The thyroid ultrasonography showed a 1.4 × 1.0 cm hypoechogenic solid nodule with irregular borders and microcalcifications located in the right lobe. No cervical lymph nodules were found. Fine-needle aspiration of the nodule displayed a Bethesda VI category. Total thyroidectomy was performed. No lymph node dissection was implemented. During surgery, the thyroid parenchyma was diffusely black in color, increased in size, and multinodular. The patient was uneventfully discharged on postoperative day 1. Histopathology revealed a diffuse black discoloration of the specimen with a well-defined 1.2×0.8×0.6 cm nodule in the right upper lobe with features of classic papillary thyroid carcinoma. Recently the patient was seen at his 3-month follow-up, and there were no signs or symptoms of recurrence or metastasis.

Clinical lessons: Although several studies describe a higher incidence of malignancy (being papillary thyroid carcinoma the most frequently associated) in black thyroid compared to non-black thyroid glands, a causal relationship has never been proven. Perhaps in this case the thyroid ultrasonography screening triggered the overdiagnosis and subsequently the overtreatment. Finally, having a "black organ" can be distressing for patients. Therefore, we should be meticulous in explaining "this disturbing fact".

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

RF11 | PSAT249 Radiofrequency Ablation for Thyroid Nodules: The First Ecuadorian Prospective Cohort

Introduction

Radiofrequency ablation (RFA) is a promising, non-surgical method, used for the treatment of benign and malignant thyroid nodules (TN). While this minimally invasive technique has been studied extensively in Europe and Asia, it has been recently adopted in Latin America. The aim of our study is to describe the clinical outcomes following the first cohort of TN subjected to ablative radiofrequency in Ecuador.

Methods

This single-center, prospective study, carried out at ITECC (Instituto de la Tiroides y Enfermedades de Cabeza y Cuello) in Ecuador, included adults who underwent RFA for benign and malignant thyroid nodules (TN), between September 2020 and January 2022. The trans-isthmic approach and moving shot technique using the RF Medical equipment with an 18G needle and 5 or 7 mm tip were applied. Nodule size and volume, thyroid function, and complications were evaluated before and after RFA. Initial volume and change in TN volume were calculated with the ATA calculator and the independent-samples T-test.

Results

A total of 26 patients with 28 TNs were included. 25 TNs were benign (Bethesda II) and 3 were micropapillary thyroid cancer (MPTC) (Bethesda VI). In the benign lesions group, most were female (82.6%), <55 years of age (73.9%), euthyroid (62.5%), and symptomatic (95.6%); had a mean maximum diameter of 3.3 ± 1.3 (range: 0.8–5.5) cm and a mean initial volume of 13.1 ± 11.6 ml; and had predominantly solid component (36.4%). A substantial volume reduction was observed since the first month after RFA (1 month: mean volume 8.6 ± 4.2 ml, p=0.01; 6 months: mean volume 4.5 ± 3.9 ml, p=0.04; and 12 months: mean volume 4.9 ± 6.9 ml, p=0.25; vs. baseline). All patients were asymptomatic at the last follow-up. In the MPTC group, two patients were males (66.7%); all were <55 years of age (100.0%) and euthyroid (100.0%); most were asymptomatic diagnosed by routine US (66.7%); had a mean maximum diameter of 0.6 ± 0.1 (range: 0.5–0.8) cm and a mean initial volume of 0.056 ± 0.001 ml. At 1-month follow-up after RFA all TN were fibrosed and no lymph node or distant metastases were found. Finally, in both groups, no major complications were found and only one patient reported ecchymosis at the puncture site. Thyroid function was not affected.

Conclusions

To the best of our knowledge, we are the pioneers in Ecuador and the third country, after Brazil and Colombia, in Latin America that implemented RFA in the management of TN. In our first experience, RFA was a safe and effective technique. RFA induced a substantial volume reduction, improved symptoms, avoided cosmetic concerns, and did not affect normal thyroid function. Our results are consistent with other series. Data on a longer follow-up are needed to confirm long-term efficacy.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m.

PSAT377 Minimally Invasive Treatment Modalities or Active Surveillance Compared to Surgery for Patients with Small Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis

Background

The incidence of thyroid cancer is increasing worldwide. A third of new thyroid cancer cases are small papillary thyroid cancer (1.5 cm or less in size). Although surgical intervention is the most common management option for patients with small papillary thyroid cancer (SPTC), active surveillance (AS), radiofrequency ablation (RFA), laser ablation (LA), and microwave ablation (MWA) are also considered as management alternatives. This study aimed to assess the comparative effectiveness of surgical (TS) vs. non-surgical management options for patients with SPTC.

Methods

We included studies comparing any type of TS versus AS, LA, RFA, or MWA in patients with a biopsy-proven SPTC of less than 1.5 cm without evidence of preoperative local or distant metastasis. The outcomes of interest were risk of recurrence of thyroid cancer, disease-specific mortality, and quality of life (QoL). All outcomes were measured at the longest follow-up. Literature search used Cochrane Database, Embase, and MEDLINE from inception to June 3rd, 2020. The CLARITY tool was used to assess the risk of bias. For dichotomous outcomes, we calculated odds ratios (OR) and their corresponding 95% confidence intervals (CI) using random-effects models. We estimated mean differences (MD) and standardized mean differences (SMD) based on predetermined criteria for continuous outcomes. PROSPERO (CRD42021235657).

Results

We included 14 retrospective cohort studies consisting of 6457 patients. TS, AS, RFA, MWA, and LA therapies were performed in 67.50% (n=4291), 21.03% (n=1337), 7.53% (n=479), 2.49% (n=255), and 1.27% (n=81) of cases, respectively. Disease-specific mortality (mean follow-up ranged from 37.5 to 120.0 months) was not different between patients who underwent TS versus AS. There was no data on mortality for the other noninvasive approaches. The risk of recurrence (mean follow-up ranged from 17.0 to 49.2 months) was not different when comparing LA, RFA, AS, or MWA against TS. The overall physical health domain of QoL (mean follow-up ranged from 10.8 to 29.6 months) was increased in patients who underwent AS (SMD: 0.23 95%CI 0.09; 0.37, k=2, I2=0.00%) compared to TS, but it was no different when comparing MWA or RFA versus TS. In addition, there were no differences in the overall mental health domain of QoL comparing AS or RFA vs TS. The risk of bias was considered moderate in nine studies and high in five studies.

Conclusion

Low evidence quality suggests equal risk of recurrence and mortality between SPTC patients who underwent minimally invasive treatment modalities or active surveillance compared to surgery. However, physical QoL was better in SPTC patients who underwent AS. Further studies are needed to confirm these results and draw robust conclusions.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT323 Ultrasound-guided Percutaneous Ethanol Ablation for the treatment of Benign Cystic Thyroid Nodules: Report of Three Cases on The Initial Ecuadorian Experience

Introduction

Ultrasound-guided Percutaneous Ethanol Ablation (UPEA) is one of the first-line treatments for benign pure cysts and predominantly cystic thyroid nodules (TN). This non-surgical procedure has been used for years worldwide, however, in Latin America, this was recently adopted. Therefore, the aim of this report is to characterize our initial experience with UPEA in Ecuador.

Clinical cases description: We report on the cases of a woman (F1: 49 y) and two men (M1: 38 y, M2: 69 y) that underwent UPEA for three predominantly cystic TN at ITECC (Instituto de la Tiroides y Enfermedades de Cabeza y Cuello) in Ecuador. All nodules were non-functioning and graded as Bethesda II. Our approach in regards to the total ethanol volume injected was approximately calculated at 1/3 of the TN volume, using 75% ethanol. 10 ml of 2% lidocaine was used for anesthetic purposes. Initial volume and change in TN volume were calculated with the ATA calculator. Patient F1 had a 40 mm (23.5 ml) right lobe TN and underwent needle extraction of 5 ml of cystic fluid before the injection of 6 ml of ethanol. At 1-month follow-up, the nodule reduced 78.1% in volume (28 mm, 5.1 ml). Similarly, patient M1 had a 59 mm (44.8 ml) right lobe TN treated with 6 ml of ethanol after 20 ml of cystic fluid was extracted from the TN. At 3-month follow-up, the nodule reduced 99% in volume (7 mm, 0.1 ml). Finally, patient M2 had a 36 mm (14.5 ml) right lobe TN treated with 5 ml of ethanol. At 6-moth follow-up, the nodule reduced 99% in volume (0.5 mm, 0.04 ml). No patients developed complications and only needed one session.

Conclusions

To the best of our knowledge, we are the pioneers in Ecuador and the fourth country in Latin America that implemented UPEA in the management of cystic TN. In this small report, UPEA seems to be an effective and safe treatment option for cystic TN. Patients had >75% reduction in cyst volume along with symptomatic relief and no complications. Our results are consistent with other series. Data on a longer follow-up are needed to confirm long-term efficacy.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT243 Late Versus Early Administration of Radioiodine Therapy for Patients with Differentiated Thyroid Cancer: A Systematic Review and Meta-analysis

Background

Radioiodine (RAI) therapy is an important adjuvant therapy for differentiated thyroid carcinoma (DTC) patients. Several studies have demonstrated the efficacy of RAI in reducing the risk of thyroid cancer recurrence and mortality; however, the ideal timing to initiate RAI after surgery is debatable. This systematic review and meta-analysis evaluates the risk of achieving excellent response and mortality when comparing late administration versus early administration of RAI in patients with DTC.

Methods

We searched Medline, Embase, Scopus, and Cochrane Database from inception to April 2021 to identify experimental and observational studies that evaluated the impact of different timings of RAI after surgery (<3 months vs. >3 months, <6 months vs. >6 months, <9 months vs. >9 months) on the risk of excellent response and thyroid-specific mortality in DTC patients with low, intermediate, and high risk of recurrence. We used random-effects model to pool dichotomous variables with odd ratios (OR) and their confidence intervals (95%CI). The risk of bias was evaluated using the Newcastle Ottawa Scale. PROSPERO Protocol ID CRD42021267036.

Results

We included 12 retrospective cohort studies with 34,833 patients. The majority of participants were female (78.00%) and the mean age ranged from 39.70 (± 3.40) to 51.60 (± 1.70) years. In patients with low-to-intermediate risk of recurrence, there were no differences in excellent response (OR 0.76, 95%CI: 0.34-1.68, I²: 78.00%, n=1099) and mortality risk (OR 1.00, 95%CI: 0.84-1.19, I²: 0.00%, n=21450) in the late group (>3 months) compared to the early group (<3 months). The same outcomes were obtained for DTC patients who underwent RAI at 6 months (excellent response, OR 1.26, 95%CI: 0.94-1.69, I²: 0.00%, n=880) and at 9 months cut-offs (excellent response, OR 0.78, 95%CI: 0.32-1.91, I²: 0.00%, n=597; mortality, OR 1.28, 95%CI: 0.74-2.23, I²: 0.00%, n=327). Regarding DTC patients with high risk of recurrence, there were no differences in excellent response (OR 0.82, 95%CI: 0.61-1.11, I²: 0.00%, n=720) and mortality risk (OR 1.04, 95%CI: 0.74-1.47, I²: 62.50, n=10426) in the late group (>3 months) when compared to the early group (<3 months). Similarly for patients who underwent RAI at 6 months cut-off (excellent response, OR 1.04, 95%CI: 0.64-1.68, I²: 58.90%, n=72). However, mortality risk was higher in the late group (>6 months) when compared to the early group (<6 months) (OR 6.55, 95%CI: 2.92-14.67, I²: 0.00%, n=198). The risk of bias was considered moderate in 7 studies and high in 5.

Conclusions

Low-to-moderate quality of evidence suggests increased mortality with delayed RAI (>6 months) in DTC patients with high risk of recurrence. The timing of RAI for other risk categories has little or no effect. Further experimental studies are needed to confirm these results and draw robust conclusions.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PSAT281 Crico-tracheal Resection with End-to-End Anastomosis for Locally Advanced Thyroid Cancer: A Case Series of Early Postoperative Outcomes of a Low-Income Country from Latin America

Introduction

Tracheal invasion is a poor prognostic factor in patients with aggressive thyroid cancer. Crico-tracheal resection and primary anastomosis (CTRA) is the preferred surgical technique. Appropriate resection can improve early postoperative outcomes and long-term oncological outcomes. A recent systematic review of eastern literature showed a moderate rate of postoperative complications. However, there is a paucity of data regarding early postoperative complications in Latin America. Therefore, the aim of this report is to describe the early postoperative outcomes of three patients with thyroid cancer invading the trachea who underwent CTRA in two tertiary referral centers (1 public and 1 private) in a low-income country.

Clinical Cases

There were 2 females (F1: 53 y, F2: 55 y) and 1 male (M1: 53 y) patients from Ecuador. Patient F1 had follicular variant of papillary thyroid cancer (PTC) and was operated on in the public center and patients F2 and M1 had classic variant of PTC. Neck CT and perioperative flexible endoscopy were performed for airway invasion assessment. All patients underwent total thyroidectomy with circumferential CTRA. Patient F1 had a right lobe thyroid tumor with intraluminal invasion of the 5th tracheal ring up to the cricoid cartilage, the recurrent laryngeal nerve (RLN) and common carotid artery, and bilateral central neck lymph node metastasis. She underwent bilateral central neck dissection, carotid shaving, and RLN resection. Patient F2 showed an enlarged, multinodular thyroid invading the 4th up to the 1st tracheal ring, without luminal compromise. There was no invasion to other structures. Patient M1 had a right lobe thyroid tumor, with intraluminal invasion of the 4th tracheal ring up to the cricoid cartilage and invasion of the RLN. He underwent RLN resection. Patient F1 and M1 were classified as Shin IV and patient F2, Shin III. Regarding the 30-day postoperative complications, patient F1 had tracheostomy infection on day 5, tracheal dehiscence and anastomotic dehiscence that caused massive bleeding, cardiorespiratory failure and death on day 8. Patient M1 only presented mild bleeding through the traqueostomy tube on day 1, non-compressive cervical hematoma on day 2, and was discharged on day 5. Patient F2 had no complications and was discharged on day 3. The last 2 patients were decanulated successfully at the 2-week follow-up and received adjuvant radioactive iodine.

Conclusions

CTRA seems to be a safe procedure with moderate postoperative complications, low mortality, and zero tracheotomy-dependency rates in patients operated in Ecuador. Our results are similar to those described in the international literature. Further studies are needed to confirm these results and draw robust conclusions.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A Comparative Analysis of a Self-Reported Adverse Events Analysis after Receiving One of the Available SARS-CoV-2 Vaccine Schemes in Ecuador

The COVID-19 pandemic has put a lot of pressure on health systems worldwide. Mass vaccination against SARS-CoV-2 has reduced morbidity and mortality worldwide. Despite their safety profiles, vaccines, as with any other medical product, can cause adverse events. Yet, in countries with poor epidemiological surveillance and monitoring systems, reporting vaccine-related adverse events is a challenge. The objective of this study was to describe self-reported vaccine adverse events after receiving one of the available COVID-19 vaccine schemes in Ecuador. A cross-sectional analysis based on an online, self-reported, 32-item questionnaire was conducted in Ecuador from 1 April to 15 July 2021. Participants were invited by social media, radio, and TV to voluntarily participate in our study. A total of 6654 participants were included in this study. Furthermore, 38.2% of the participants reported having at least one comorbidity. Patients received AstraZeneca, Pfizer, and Sinovac vaccines, and these were distributed 38.4%, 31.1%, and 30.5%, respectively. Overall, pain or swelling at the injection site 17.2% (n = 4500) and headache 13.3% (n = 3502) were the most reported adverse events. Women addressed events supposedly attributable to vaccination or immunization [ESAVIs] (66.7%), more often than men (33.2%). After receiving the first dose of any available COVID-19 vaccine, a total of 19,501 self-reported ESAVIs were informed (87.0% were mild, 11.5% moderate, and 1.5% severe). In terms of the vaccine type and brand, the most reactogenic vaccine was AstraZeneca with 57.8%, followed by Pfizer (24.9%) and Sinovac (17.3%). After the second dose, 6776 self-reported ESAVIs were reported (87.1% mild, 10.9% moderate, and 2.1% severe). AstraZeneca vaccine users reported a higher proportion of ESAVIs (72.2%) in comparison to Pfizer/BioNTech (15.9%) and Sinovac Vaccine (11.9%). Swelling at the injection site, headache, muscle pain, and fatigue were the most common ESAVIs for the first as well as second doses. In conclusion, most ESAVIs were mild. AstraZeneca users were more likely to report adverse events. Participants without a history of COVID-19 infection, as well as those who received the first dose, were more prone to report ESAVIs.

Robotic Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis

The introduction of robotics in living donor liver transplantation has been revolutionary. We aimed to examine the safety of robotic living donor right hepatectomy (RLDRH) compared to open (ODRH) and laparoscopic (LADRH) approaches. A systematic review was carried out in Medline and six additional databases following PRISMA guidelines. Data on morbidity, postoperative liver function, and pain in donors and recipients were extracted from studies comparing RLDRH, ODRH, and LADRH published up to September 2020; PROSPERO (CRD42020214313). Dichotomous variables were pooled as risk ratios and continuous variables as weighted mean differences. Four studies with a total of 517 patients were included. In living donors, the postoperative total bilirubin level (MD: −0.7 95%CI −1.0, −0.4), length of hospital stay (MD: −0.8 95%CI −1.4, −0.3), Clavien−Dindo complications I−II (RR: 0.5 95%CI 0.2, 0.9), and pain score at day > 3 (MD: −0.6 95%CI −1.6, 0.4) were lower following RLDRH compared to ODRH. Furthermore, the pain score at day > 3 (MD: −0.4 95%CI −0.8, −0.09) was lower after RLDRH when compared to LADRH. In recipients, the postoperative AST level was lower (MD: −0.5 95%CI −0.9, −0.1) following RLDRH compared to ODRH. Moreover, the length of stay (MD: −6.4 95%CI −11.3, −1.5) was lower after RLDRH when compared to LADRH. In summary, we identified low- to unclear-quality evidence that RLDRH seems to be safe and feasible for adult living donor liver transplantation compared to the conventional approaches. No postoperative deaths were reported.

Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies

PURPOSE

Access to health care is a long-standing concern for rural patients; however, administrative measures fail to capture the subjective patient experience of accessing health care. The purpose of this review was to synthesize the qualitative literature on patient and caregiver experiences of accessing health care services for chronic disease management among US residents of rural areas.

METHODS

We searched Embase, MEDLINE, PsycInfo, CINAHL, and Scopus to identify qualitative studies published during 2010-2019. A thematic synthesis approach was used to analyze findings from included studies.

RESULTS

A total of 62 studies involving 1,354 unique participants were included. The largest share of studies (24.2%) was focused on the experience of patients with cancer, followed by behavioral health (16.1%), HIV and AIDS (14.5%), and diabetes (12.9%). We identified 4 primary analytic themes of barriers and facilitators associated with the experience of accessing health care services for chronic disease management in rural areas: (1) navigating the rural environment, (2) navigating the health care system, (3) financing chronic disease management, and (4) rural life (ie, common elements of a distinct "rural" way of thinking and behaving).

CONCLUSIONS

In this comprehensive review, we found that important cultural, structural, and individual factors influenced the rural patient's experience of health care access and use, including barriers and facilitators posed by geographic and built environments, and distinct rural mores. Our findings can inform policies and programs that both facilitate structural aspects of access and include culturally appropriate interventions.VISUAL ABSTRACT.