Operation rooms have a large environmental impact. Single-use staplers (SUS) are widely used surgical instruments that contribute to resource consumption and waste generation, whereas multi-use staplers (MUS) can greatly reduce the environmental impact of surgery. The staple lines are often reinforced with buttressing material to prevent leaks and bleeding. We explore current clinical practice and environmental concerns regarding stapling and buttressing, as well as the environmental impact of staple line buttressing in sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Furthermore, we extend this analysis by taking packaging material and the lithium in power supplies into consideration. Materials and Methods: A survey of bariatric surgeons was conducted to assess stapler and buttressing use in clinical practice. We deconstructed and analyzed the product and packaging composition of a commonly used SUS with separate staple line reinforcement (Echelon Flex™ with Echelon Endopath™, Ethicon) and MUS (Signia™ with Tri-Staple™ reinforced reloads, Medtronic), where the buttressing material was delivered separately or already incorporated in the reload cartridge, respectively. Both systems were compared regarding total waste generation, resource use (determined as total material requirement), and greenhouse gas emission caused by their lithium content. Results: 60 mm cartridges were most frequently used in bariatric surgery, and 67% of surveyed surgeons applied staple line reinforcement. MUS with pre-attached buttressing resulted in a reduction of waste, material consumption, and greenhouse gas emissions compared to SUS with separate buttressing: they reduced product waste by 40% (SG and RYBG), packaging waste by 60% (SG) and 57% (RYGB), resource consumption by more than 90%, and greenhouse gas emissions related to the lithium in the batteries by 99.7%. Preloaded buttressing produced less waste than separate buttressing per stapler firing. Conclusion:The environmental impact of surgery can be greatly reduced by using MUS with pre-attached buttressing rather than SUS with separate buttressing.

Objective To evaluate the cost-effectiveness of using mechanical thromboprophylaxis for patients undergoing a cesarean delivery in Brazil. Methods A decision-analytic model built in TreeAge software was used to compare the cost and effectiveness of intermittent pneumatic compression to prophylaxis with low-molecular-weight heparin or no prophylaxis from the perspective of the hospital. Related adverse events were venous thromboembolism, minor bleeding, and major bleeding. Model data were sourced from peer-reviewed studies through a structured literature search. A willingness-to-pay threshold of R$15,000 per avoided adverse event was adopted. Scenario, one-way, and probabilistic sensitivity analyses were performed to evaluate the impact of uncertainties on the results. Results The costs of care related to venous thromboembolism prophylaxis and associated adverse events ranged from R$914 for no prophylaxis to R$1,301 for low-molecular-weight heparin. With an incremental cost-effectiveness ratio of R$7,843 per adverse event avoided. Intermittent pneumatic compression was cost-effective compared to no prophylaxis. With lower costs and improved effectiveness, intermittent pneumatic compression dominated low-molecular-weight heparin. The probabilistic sensitivity analyses showed that the probability of being cost-effective was comparable for intermittent pneumatic compression and no prophylaxis, with low-molecular-weight heparin unlikely to be considered cost-effective (0.07). Conclusions Intermittent pneumatic compression could be a cost-effective option and is likely to be more appropriate than low-molecular-weight heparin when used for venous thromboembolism prophylaxis for cesarean delivery in Brazil. Use of thromboprophylaxis should be a risk-stratified, individualized approach.

ALT), gamma glutamyl transferase (GGT), alkaline phosphatase (ALP) and total bilirubin (TB)), dose, diagnosis, age and sex were registered.Microsoft Excel was used for the statistics calculation. Results 68 determinations in 38 patients (73.75% men; aged 64.84 ±11.29 years).Diagnosis: probable disease 21 (55.28%), possibility 12 (31.57%), prophylaxis 5 (13.15%).6 (15.8%) patients needed a change in treatment. 5 (83.33%) had the dose changed in order to maintain plasma levels between 1 and 5.5 mg/mL. In 1 patient (16.66%) voriconazole was substituted.28 (73.7%) started treatment with the dose of 200 mg/12 hours, whereas the rest (26.3%) has a higher dose. 60% of dose changes were in patients taking 200 mg/12 hours.A positive correlation existed between plasma levels of voriconazole and liver enzymes as well as with cholestasis markers (AST: r 2 =0.1817; ALT: r 2 =0.1118; GGT: r 2 =0.2528; PA: r 2 =0.2444 and TB: r 2 =0.4637).The Chi-square statistic was significant at p<0.05 for plasmatic levels over 3 mg/mL and AST/ALT over physiological range (35 U/L).The relative risk of presenting ALT over the physiological range is 3.12 and for AST 2.31 in patients with plasmatic levels of voriconazole >3 mg/mL respects the ones whose plasmatic levels were <3 mg/mL. Conclusion and relevanceVoriconazole TDM is a tool that can help to avoid treatment failure and adverse events. Its relationship with liver toxicity, which shows our data, TDM would help to prevent these side effects.