Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

Improving the antinutritional profiles of common beans (Phaseolus vulgaris L.) moderately impacts carotenoid bioaccessibility but not mineral solubility.

Common beans are a common staple food with valuable nutritional qualities, but their high contents in antinutritional factors (ANFs) can decrease the bioavailability of (i) fat-soluble micronutrients including carotenoids and (ii) minerals. Our objective was to select ANF-poor bean lines that would not interfere with carotenoid and mineral bioavailability. To achieve this objective, seeds of commercial and experimental Phaseolus vulgaris L. bean lines were produced for 2 years and the bean's content in ANFs (saponins, phytates, tannins, total polyphenols) was assessed. We then measured carotenoid bioaccessibility and mineral solubility (i.e. the fraction of carotenoid and mineral that transfer into the aqueous phase of the digesta and is therefore absorbable) from prepared beans using in vitro digestion. All beans contained at least 200 mg/100 g of saponins and 2.44 mg/100 g tannins. The low phytic acid (lpa) lines, lpa1 and lpa12 exhibited lower phytate levels (≈ - 80%, p = 0.007 and p = 0.02) than their control BAT-93. However, this decrease had no significant impact on mineral solubility. HP5/1 (lpa + phaseolin and lectin PHA-E free) bean line, induced an improvement in carotenoid bioaccessibility (i.e., + 38%, p = 0.02, and + 32%, p = 0.005, for phytofluene bioaccessibility in 2021 and 2022, respectively). We conclude that decrease in the phytate bean content should thus likely be associated to decreases in other ANFs such as tannins or polyphenols to lead to significant improvement of micronutrient bioaccessibility.

Customized Cochlear Implant Positioning in a Patient With a Low- Grade Glioma: Towards the Best MRI Artifact Management.

OBJECTIVE: To report the personalized decision-making pro- cess adopted for a cochlear implant (CI) candidate requiring magnetic resonance imaging (MRI) brain surveillance. STUDY DESIGN: Clinical capsule report. SETTING: Tertiary academic referral center. PATIENT: A 23-year-old man affected by posttraumatic bilat- eral profound hearing loss, already in radiological follow-up for a suspected small left cuneal low-grade glioma. INTERVENTIONS: A multidisciplinary approach involving preoperative MRI simulations and 3D printed (3DP) models aiming to adapt the CI position to facilitate MRI brain lesion visibility. MAIN OUTCOME MEASURES: MRI visibility and surgical approach. RESULTS: Preoperative MRI scans with the placement of an Ultra 3D CI were performed simulating different implant location to assess the brain lesion visibility in MRI. CI was positioned 9 cm away from the external auditory canal with an angle of 90 degrees. To assess the technical feasibility of the surgical procedure, a patient-specific 3DP head model was produced preoperatively. The postoperative course was uneventful, the patient showed a significant benefit from CI, and the brain lesion was highly visible at the MRI follow-up. CONCLUSIONS: The employment of strategies aimed at improving the MRI quality in CI recipients still represents a topic requiring attention. Thanks to multidisciplinary team collaboration, in our case, the CI position was successfully determined to allow unhindered MRI visibility of a specific intracranial structure.

A novel quantitative analysis method for idiopathic epiretinal membrane.

PURPOSE: To introduce a novel method to quantitively analyse in three dimensions traction forces in a vast area of the ocular posterior pole. METHODS: Retrospective analysis of 14 eyes who underwent peeling surgery for idiopathic, symptomatic and progressive epiretinal membrane. The technique measures the shift in position of vascular crossings after surgery from a fixed point, which is the retinal pigmented epithelium. This shift is defined as the relaxation index (RI) and represents a measure of the postoperative movement of the retina due to released traction after surgery. RESULTS: Best-corrected visual acuity was significantly better than baseline at all follow ups while the RI had its maximum value at baseline. Moreover, we found a significant correlation between best-corrected visual acuity at 6 months and RI at baseline. CONCLUSION: While all previous published methods focused on bi-dimensional changes observed in a small region, this study introduces a three-dimensional assessment of tractional forces. Future integration of RI into built-in processing software will allow systematic three-dimensional measurement of intraretinal traction.

Multidisciplinary preoperative simulations to optimize surgical outcomes in a challenging case of the complete double aortic arch in the adult.

BACKGROUND: Challenging surgical cases are becoming more and more frequent, making the optimization of decision making process and an accurate preoperative planning mandatory in order to improve postoperative outcomes. AIMS: Here we present an original multidisciplinary approach aimed at optimizing decision making in a peculiar case of double aortic arch (DAA) presenting in an adult patient. MATERIALS AND METHODS: Following the diagnosis of DAA, based on conventional exams, a three steps engineering simulation was adopted including: a) three-dimensional (3D) rapid prototype simulation; b) computational fluid-dynamic analysis; c) 3D virtual simulation of surgical exposure. RESULTS: Based on careful evaluation of such simulations we were able to identify optimal anatomical and functional surgical options, along with the optimal surgical approach. DISCUSSION: In peculiar clinical case, a significant step forward to optimize preoperative surgical planning could be obtained applying current available engineering techniques. CONCLUSION: We do believe that a multidisciplinary approach could become mandatory, in challenging cases, to optimize preoperative planning and outcomes.

Feasibility of 3D printed salivary duct models for sialendoscopic skills training: preliminary report.

PURPOSES: To explore the feasibility of 3D printed salivary duct models for the sialendoscopic skills training. METHODS: Healthy volunteers and patients affected by obstructive salivary gland disorders were submitted to 3 Tesla MR sialography. The MR data underwent an image segmentation process to produce the 3D printed salivary duct prototypes. Sialendoscopies were carried out by three groups of investigators with different levels of endoscopic experience. Realism, usefulness of the training process and potential advantages of the 3D printed models in the preoperative surgical planning were evaluated by means of a specific survey. RESULTS: Four cases were included in our study: one healthy parotid, one submandibular gland, one case of lithiasis and one of stenosis involving the parotid gland. In all cases, the three groups of investigators successfully explored the salivary ducts up to the tertiary branches, detected the cause of obstruction and correctly treated it. Seven untoward events occurred during the operative sialendoscopies. Overall, the questionnaire score was about 79.3%, reflecting a positive impression regarding the models on behalf of all the investigators. CONCLUSIONS: 3D printed salivary duct models resulted feasible for the sialendoscopic skills training. The opportunity to reproduce the patient-specific anatomy may add further information useful in the preoperative decision making. These positive results should be verified by further researches and experiences.

An overview on 3D printing for abdominal surgery.

BACKGROUND: Three-dimensional (3D) printing is a disruptive technology that is quickly spreading to many fields, including healthcare. In this context, it allows the creation of graspable, patient-specific, anatomical models generated from medical images. The ability to hold and show a physical object speeds up and facilitates the understanding of anatomical details, eases patient counseling and contributes to the education and training of students and residents. Several medical specialties are currently exploring the potential of this technology, including general surgery. METHODS: In this review, we provide an overview on the available 3D printing technologies, together with a systematic analysis of the medical literature dedicated to its application for abdominal surgery. Our experience with the first clinical laboratory for 3D printing in Italy is also reported. RESULTS: There was a tenfold increase in the number of publications per year over the last decade. About 70% of these papers focused on kidney and liver models, produced primarily for pre-interventional planning, as well as for educational and training purposes. The most used printing technologies are material jetting and material extrusion. Seventy-three percent of publications reported on fewer than ten clinical cases. CONCLUSION: The increasing application of 3D printing in abdominal surgery reflects the dawn of a new technology, although it is still in its infancy. The potential benefit of this technology is clear, however, and it may soon lead to the development of new hospital facilities to improve surgical training, research, and patient care.

Bioink Composition and Printing Parameters for 3D Modeling Neural Tissue.

Neurodegenerative diseases (NDs) are a broad class of pathologies characterized by the progressive loss of neurons in the central nervous system. The main problem in the study of NDs is the lack of an adequate realistic experimental model to study the pathogenic mechanisms. Induced pluripotent stem cells (iPSCs) partially overcome the problem, with their capability to differentiate into almost every cell types; even so, these cells alone are not sufficient to unveil the mechanisms underlying NDs. 3D bioprinting allows to control the distribution of cells such as neurons, leading to the creation of a realistic in vitro model. In this work, we analyzed two biomaterials: sodium alginate and gelatin, and three different cell types: a neuroblastoma cell line (SH-SY5Y), iPSCs, and neural stem cells. All cells were encapsulated inside the bioink, printed and cultivated for at least seven days; they all presented good viability. We also evaluated the maintenance of the printed shape, opening the possibility to obtain a reliable in vitro neural tissue combining 3D bioprinting and iPSCs technology, optimizing the study of the degenerative processes that are still widely unknown.

3D printing of aortic models as a teaching tool for improving understanding of aortic disease.

BACKGROUND: A geometrical understanding of the individual patient's disease morphology is crucial in aortic surgery. The aim of our study was to validate a questionnaire addressing understanding of aortic disease and use this questionnaire to investigate the value of 3D printing as a teaching tool for surgical trainees. METHODS: Anonymized CT-angiography images of six different patients were selected as didactic cases of aortic disease and made into 3D models of transparent rigid resin with the Vat-photopolymerization technique. The 3D aortic models, which could be disassembled and reassembled, were displayed to 37 surgical trainees, immediately after a seminar on aortic disease. A questionnaire was developed to compare the trainees' understanding before (T0) and after (T1) demonstration of the 3D printed models. RESULTS: A panel of 15 experts participated in evaluating face and content validity of the questionnaire. The questionnaire validity was established and therefore the information investigated by the questionnaire could be synthetized using the mean of the items to indicate the understanding. The participants (mean age 28 years, range 26-34, male 59%) showed a significant improvement in understanding from T0 (median=7.25; IQR=1.50) to T1 (median=8.00; IQR=1.50; P=0.002). CONCLUSIONS: Preliminary data suggest that the use of 3D-printed aortic models as a teaching tool was feasible and improved the understanding of aortic disease among surgical trainees.

Antioxidant Properties of Four Commonly Consumed Popular Italian Dishes.

Four popular dishes belonging to Italian cuisine and widely consumed in the country were experimentally prepared in a dedicated lab-kitchen following a validated and standardized protocol. This study provides their antioxidant properties evaluating the contribution of extractable and non-extractable bioactive compounds, and identifying the assessment of interactions between their natural active compounds and the food matrix. Ferric reducing antioxidant power (FRAP) values in aqueous-organic extract ranged from the highest antioxidant activity in torta di mele (10.72 µmol/g d.m.) to that in besciamella (2.47 µmol/g d.m.); in residue, pasta alla carbonara reached the highest value (73.83 µmol/g d.m.) following by that in pasta alla amatriciana (68.64 µmol/g d.m.). Total polyphenol content (TPC) ranged in aqueous-organic extracts between 36.50 and 64.28 mg/100 g d.m. and in residue from 425.84 to 1747.35 mg/100 g d.m. Our findings may contribute to the updating of the Italian Food Composition Database, by providing for the first time a value for the antioxidant properties. This could contribute to encourage the consumption of recipes rich in key nutrients and bioactive molecules. This information is useful and important for determining the association between diet and a healthy status.

Twelve-year Follow-up Post-Thoracic Endovascular Repair in Type B Aortic Dissection Shown by Three-dimensional Printing.

BACKGROUND: Thoracic endovascular repair (TEVAR) is currently considered the therapy of choice for complicated type B acute aortic dissection (TBAAD). Although several papers have reported good outcomes at short- and medium-term follow-up, some questions still remain regarding the long-term durability and re-intervention rate during follow-up. METHODS: We describe a case of a patient originally treated with TEVAR for TBAAD complicated by impending aortic rupture. RESULTS: Endovascular repair successfully excluded the flow through the primary entry tear but during the 12-year follow-up period the patient experienced several complications and re-interventions. Various full-size three-dimensional (3D) models of the patient-specific vasculature were printed to better explain the different interventional interventions over the 12 years of follow-up and as a hands-on tool for medical education. CONCLUSIONS: The present case report, involving long-term follow-up, provides an example of the effectiveness and the safety of TEVAR for the treatment of complicated TBAAD shown at short and medium-term follow-up. However, the long-term complications that were observed in this patient during follow-up support the importance of lifelong CTA surveillance. Furthermore, this study confirms the capability of 3D printing technology as a powerful tool to support communication with patients and residents' education through the physical analysis of the real cases.

The clinical use of 3D printing in surgery.

The use of 3D printing is gaining considerable success in many medical fields including surgery. Here, the technology was introduced for increasing the level of anatomical understanding thanks to the inherent characteristics of 3D printed models: these are highly accurate and customized reproductions, being obtained from own radiological imaging of patients, and are solid graspable objects allowing for free manipulation on part of the user. The resulting tactile feedbacks significantly help the comprehension of anatomical details, especially the spatial relations between structures. In this regard, they proved to be more effective than conventional 2D imaging and 3D virtual models. To date, an increasing number of applications have been successfully tested in many surgical disciplines, extending the range of possible uses to pre-operative planning, counselling with patients, education of students and residents, surgical training, intraoperative navigation and others; in recent years, 3D printing was also employed for creating surgical tools and reproducing anatomical parts to be used, respectively, as templates or guides for specific tasks of the surgery and individualized implantable materials in reconstructive procedures. Future expectations concern on one side the reduction of manufacturing costs and time to further increase the accessibility of 3D printing, while on the other the development of novel techniques and materials suitable for 3D printing of biological structures by which recreating the architecture and functionality of real human organs and tissues.

Effectiveness of 3D printed models in the treatment of complex aortic diseases.

BACKGROUND: The treatment of complex aortic diseases has known in the last years an extraordinary improvement, thanks to the development of new devices and techniques, especially concerning endovascular surgery. In this field, technological evolution has enabled vascular surgeons to overcome anatomical concerns and impairments that in the past made endovascular treatment unfeasible in many cases. However, the full exploitation of the devices offered by medical industry requires more and more powerful and accurate tools for case-by-case analysis and preoperative planning. Beside traditional imaging techniques, such as computed tomographic angiography (CTA), and virtual 3D reconstructions, an increasing interest towards 3D printing has been reported in the latest years. The purpose of this paper is to assess the actual value of this technology by reporting its use in 25 cases of complex aortic surgery. METHODS: For each patient, we have 3D printed a preoperative life-sized model of the vascular aortic lumen, deciding and planning the most suitable procedure by its direct examination. After the intervention, we have examined the corresponding model printed derived from postoperative CTA to check the outcome and discuss possible further corrections, if needed. RESULTS: All the cases for which a surgical or endovascular procedure was decided were treated successfully, in absence of major complications or intra-operative mortality. CONCLUSIONS: Optimal resolution of anatomical details and immediate comprehension of the most important technical aspects were reported by examining the models. 3D printing has proved a valuable tool in dealing with complex aortic diseases.

Modular flow chamber for engineering bone marrow architecture and function.

The bone marrow is a soft, spongy, gelatinous tissue found in the hollow cavities of flat and long bones that support hematopoiesis in order to maintain the physiologic turnover of all blood cells. Silk fibroin, derived from Bombyx mori silkworm cocoons, is a promising biomaterial for bone marrow engineering, because of its tunable architecture and mechanical properties, the capacity of incorporating labile compounds without loss of bioactivity and demonstrated ability to support blood cell formation. In this study, we developed a bone marrow scaffold consisting of a modular flow chamber made of polydimethylsiloxane, holding a silk sponge, prepared with salt leaching methods and functionalized with extracellular matrix components. The silk sponge was able to support efficient platelet formation when megakaryocytes were seeded in the system. Perfusion of the chamber allowed the recovery of functional platelets based on multiple activation tests. Further, inhibition of AKT signaling molecule, which has been shown to be crucial in regulating physiologic platelet formation, significantly reduced the number of collected platelets, suggesting the applicability of this tissue model for evaluation of the effects of bone marrow exposure to compounds that may affect platelet formation. In conclusion, we have bioengineered a novel modular system that, along with multi-porous silk sponges, can provide a useful technology for reproducing a simplified bone marrow scaffold for blood cell production ex vivo.