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.

Subpial technique in supratentorial glioma resection: state of the art and analysis of costs and effectiveness in a single institute experience

BACKGROUND

Many neurosurgeons advocate subpial technique as the best technique to remove supratentorial gliomas. However, few authors clearly defined advantages and features of this technique. The aim of our study is to describe microsurgical subpial technique related to glioma surgery, with regard to its safety and cost effectiveness.

METHODS

We analyzed retrospectively all consecutive patients surgically treated for supratentorial glioma from January 2017 to April 2018 at Neurosurgery Department of Neuromed Institute. All patients underwent to surgical glioma resection performing microsurgical subpial technique. Extent of resection and neurological complications were evaluated as primary outcomes; Karnofsky Performance Status and postoperative edema extent were secondary outcomes. Statistical analysis was obtained.

RESULTS

The study included 70 patients. Gross Total Removal was obtained in 91.3% of patients with low grade glioma (LGG) and in 81% of patients with high grade glioma. Neurological complications amounted to 34% at early assessment in LGG patients, which were permanent at 3 months in 17% of patients. In high grade glioma patients, neurological complications amounted to 51% at early assessment, which were permanent at 3 months in 25% of them.

CONCLUSIONS

We obtained good postoperative results with regard to the extent of tumor resection using this technique. Subpial resection is an effective surgical technique to get a safer and more complete tumor resection. It should be combined with other modern neurosurgical tools such as neuronavigation, ultrasound and cortical mapping to obtain the best tumor resection and functional neurological preservation.

Continuous subcortical monitoring of motor pathways during glioma surgery with ultrasonic surgical aspirator: technical description in a single institute experience

BACKGROUND

Actual challenge in surgical treatment of intra-axial gliomas involving eloquent areas is maximal safe resection. Mapping and monitoring of cortical and subcortical motor functionsare important tools to avoid postoperative deficits. In the present study, we present our experiencewith a continuous dynamic motor mapping technique pairing a traditional monopolar stimulatorwith a Cavitron Ultrasonic Surgical Aspirator (CUSA) to perform a continuous stimulation ofthe white matter avoiding removal interruption.

METHODS

We describe a single center retrospective analysis of 1-year consecutive patients with intraxial tumors located adjacent to corticospinal tract and treated with surgical resection adopting "continuous dynamic mapping technique". With the support of a reconstruction software (3D Slicer), we classified the Extent Of Resection (EOR) as Gross Total Resection (GTR) (>98%), Sub-Total Resection (STR) (from 90% to 97%), and Partial Resection (<90%). Medical Research Council (MRC) grading was adopted to evaluate neurological outcomes (from 0 to 5), assessed on 1st post-operative day, at 1 week, 1 month and 3 months.

RESULTS

From July 2017 to July 2018, 29 patients underwent to surgical removal of intraxial tumor adjacent to motor areas, using continuous dynamic subcortical mapping. Median age was 54 years old (range 12-75 years). At pre-operative MRI tractography reconstruction, mean distance between tumor and corticospinal tract was 4,4 mm (range At 1 week post-operative assessment, motor deficits were still present in 12 patients (41%). At 1 month, 10 patients (35%) had persisting deficits, which required admission to rehabilitation department. At 3 months, 4 patients (14%) had persistent motor impairment and overall 28 patients (98%) were able to walk by themselves.

CONCLUSIONS

Our early experience showed that a combination of dynamic subcortical mapping with transcranial and cortical strip MEP (Motor Evoked Potentials) monitoring is useful in tumors close to motor eloquent areas to extend surgical resection avoiding permanent consequences. However, we need for further experience to consolidate and improve this technique.

Casemix, management, and mortality of patients rreseceiving emergency neurosurgery for traumatic brain injury in the Global Neurotrauma Outcomes Study: a prospective observational cohort study

BACKGROUND

Traumatic brain injury (TBI) is increasingly recognised as being responsible for a substantial proportion of the global burden of disease. Neurosurgical interventions are an important aspect of care for patients with TBI, but there is little epidemiological data available on this patient population. We aimed to characterise differences in casemix, management, and mortality of patients receiving emergency neurosurgery for TBI across different levels of human development.

METHODS

We did a prospective observational cohort study of consecutive patients with TBI undergoing emergency neurosurgery, in a convenience sample of hospitals identified by open invitation, through international and regional scientific societies and meetings, individual contacts, and social media. Patients receiving emergency neurosurgery for TBI in each hospital's 30-day study period were all eligible for inclusion, with the exception of patients undergoing insertion of an intracranial pressure monitor only, ventriculostomy placement only, or a procedure for drainage of a chronic subdural haematoma. The primary outcome was mortality at 14 days postoperatively (or last point of observation if the patient was discharged before this time point). Countries were stratified according to their Human Development Index (HDI)-a composite of life expectancy, education, and income measures-into very high HDI, high HDI, medium HDI, and low HDI tiers. Mixed effects logistic regression was used to examine the effect of HDI on mortality while accounting for and quantifying between-hospital and between-country variation.

FINDINGS

Our study included 1635 records from 159 hospitals in 57 countries, collected between Nov 1, 2018, and Jan 31, 2020. 328 (20%) records were from countries in the very high HDI tier, 539 (33%) from countries in the high HDI tier, 614 (38%) from countries in the medium HDI tier, and 154 (9%) from countries in the low HDI tier. The median age was 35 years (IQR 24-51), with the oldest patients in the very high HDI tier (median 54 years, IQR 34-69) and the youngest in the low HDI tier (median 28 years, IQR 20-38). The most common procedures were elevation of a depressed skull fracture in the low HDI tier (69 [45%]), evacuation of a supratentorial extradural haematoma in the medium HDI tier (189 [31%]) and high HDI tier (173 [32%]), and evacuation of a supratentorial acute subdural haematoma in the very high HDI tier (155 [47%]). Median time from injury to surgery was 13 h (IQR 6-32). Overall mortality was 18% (299 of 1635). After adjustment for casemix, the odds of mortality were greater in the medium HDI tier (odds ratio [OR] 2·84, 95% CI 1·55-5·2) and high HDI tier (2·26, 1·23-4·15), but not the low HDI tier (1·66, 0·61-4·46), relative to the very high HDI tier. There was significant between-hospital variation in mortality (median OR 2·04, 95% CI 1·17-2·49).

INTERPRETATION

Patients receiving emergency neurosurgery for TBI differed considerably in their admission characteristics and management across human development settings. Level of human development was associated with mortality. Substantial opportunities to improve care globally were identified, including reducing delays to surgery. Between-hospital variation in mortality suggests changes at an institutional level could influence outcome and comparative effectiveness research could identify best practices.

FUNDING

National Institute for Health Research Global Health Research Group.

Intracranial soft-tissue glomus tumor (glomangioma) in a young-woman. A case report and review of the literature

BACKGROUND

Glomus tumors, or glomangiomas, are benign vascular tumors typically seen at distal extremities. These tumors differ from paragangliomas and classically present in the female population between the 4th and 5th decade. Intracranial localizations have not been described in literature in the adult population.

CASE DESCRIPTION

We present a case of a 32 year-old woman with a 3 months history of progressive left-sided visual loss and headache. A pre-operative MRI showed a homogeneously enhancing lesion extending from the left cavernous sinus to middle cranial fossa at first suspected to be a cavernous sinus meningioma. Eventually, histopathological analysis concluded for a glomangioma diagnosis. Post-operative RT was also performed.

CONCLUSIONS

From our experience it is very important for clinical management considering glomangiomas in differential diagnosis of a homogeneously enhancing extra axial mass. Subtotal resection followed by radiation therapy determined no recurrence of the disease up to 7 years.

KEY WORDS

Glomangioma, Glomus tumor, Soft-tissue tumor.

Phenotype and biochemical heterogeneity in late onset Fabry disease defined by N215S mutation

BACKGROUND

Fabry disease (FD) results from X-linked inheritance of a mutation in the GLA gene, encoding for alpha galactosidase A, and is characterized by heterogeneous clinical manifestations. Two phenotypes have been described "Classic" and "late onset" which cannot be predicted exclusively by genotype. The latter has been considered an attenuated form of the disease often affecting a single organ system commonly the heart. Recent studies have demonstrated that cardiac outcomes are similar in patients with classic and late onset mutations. In this study we investigate the relationship between clinical heterogeneity and plasma lyso-Gb3 in a large single centre cohort of N215S patients and compare this to patients with other mutations.

METHODS

In this single-centre, retrospective, cross-sectional study we analysed a cohort of 251 FD patients: 84 N215S mutation (37 males) and 167 non-N215S mutations (58 males). The Mainz severity score index (MSSI) was used as an index of overall disease severity. Cardiac function and morphology were assessed by electrocardiogram and echocardiogram. Left ventricular mass was calculated using the Devereux formula and the left ventricular mass index (LVMI) calculated to adjust for height (g/m2.7). The presence of white matter lesions was assessed by cerebral MRI or computed tomography (CT). GFR was measured by radio-isotope (chromium-EDTA) method and adjusted for patient height (ml/min/m2.7), and urinary protein quantification was undertaken by 24 hour urine collection. Plasma globotriaosylsphingosine (lyso-Gb3) was analysed prior to ERT in 84 patients.

RESULTS

N215S patients showed later symptom onset (males: p< 0.0001, females: p<0.03), later development of left ventricular hypertrophy (LVH) (median survival without LVH: 41 (non-N215S) vs. 64 (N215S) years, p< 0.0001), later development of proteinuria (median survival without proteinuria 43 (non-N215S) vs 71 years (N215S), p< 0.0001), later occurrence of cerebrovascular events (stroke/ Transient Ischaemic Attacks (TIA); median survival without stroke: 74 years (non-N215S) vs. not reached (N215S), p< 0.02), later decline in renal function to GFR <60 ml/min/1.73m2 (median survival: 56 (non-N215S) vs. 72 (N215S) years, p< 0.01), and greater overall survival (median survival 81 (N215S) vs. 66 (non-N215S) years, p< 0.0006). Lyso-Gb3 was found to be less elevated in N215S compared to non-N215S male and female patients. However, the N215S population eventually reached an overall severity measured by MSSI comparable to the non-N215S without equivalent elevation of lyso-Gb3 (means: 6.7 vs. 74.3 nmol/L, p < 0.001). In addition, N215S patients showed strong correlations between lyso-Gb3 levels and LVMI, GFR, and MSSI. These associations became stronger when we investigated individuals' life time exposure to lyso-Gb3 (calculated as [lyso-Gb3]*age): MSSI (r2 = 0.88, p< 0.0001), LVMI (r2 = 0.59, p< 0.005), and GFR (r2 = 0.75, p = 0.0001).

CONCLUSION

These results demonstrate that the N215S mutation results in a late onset phenotype involving the heart and other organs. Correlations between clinical manifestations and plasma lyso-Gb3 variations in this group suggest a Fabry-relevant disease mechanism for the heterogeneity observed in this group.

Multiple brain metastases: a surgical series and neurosurgical perspective

Despite review papers claim for radical treatment of oligometastatic patients, only few surgical series have been published. In this study, we analyze results and actual role of surgical resection for the management of patients with multiple brain metastases. This retrospective study compares surgical results of two groups of patients consecutively treated in our Institute from January 2004 to June 2015. The first group comprises all 32 patients with multiple brain metastases with only 2-3 lesions who underwent surgical resection of all lesions; the second group comprises 30 patients with a single surgically treated brain mestastasis compatible with the first group (match-paired control series). Median survival was 14.6 months for patients with multiple brain metastases (range 1-28 months) and 17.4 months for patients with a single brain metastasis (range 4-38 months); the difference was not statistically significant (P = 0.2). Neurological condition improved in 59.4% of patients with multiple metastases, it remained unchanged in 37.5% and worsened in 3.1%. In our series, selected patients with only 2-3 lesions with well-controlled systemic disease, life expectancy of more than 3 months, Karnofsky's performance status > 60, and surgically accessible lesions, benefited from surgical treatment in terms of survival and quality of life, with reduction or disappearance of significant neurological deficits. The prognosis for these patients is similar to that of patients with a single metastasis. It seems that patients with breast cancer included in our series had the worst prognosis if compared to other histotypes.

Internal haemorrhagic pachymeningiosis: specific disease or complication of chronic subdural hematoma? Report of five cases surgically treated and literature review

BACKGROUND

Internal haemorrhagic pachymeningiosis (IHP) is a rare disease characterized by a fibrous thickening and inflammatory infiltration in dural space mimicking chronic subdural hematoma. The pathogenesis of IHP is not entirely clear yet and treatment is still controversial.

OBJECTIVE

We want to emphasize the importance of differentiating pachymeningiosis from chronic subdural hematoma as distinct pathological entities.

PATIENTS AND METHODS

The records of five selected cases of IHP histologically confirmed were reviewed, focusing onset, neuroimaging, surgery and outcomes.

CONCLUSIONS

IHP is most likely underestimated. Only through multidisciplinary approach it is possible to plane the proper therapeutic strategy. The diagnosis of IHP is confirmed by definitive histology but in some cases is possible with intraoperative frozen section.