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.

Background To review the incidence of non-therapeutic thymectomies at our institution, and to identify preoperative imaging features to assist in reducing the incidence. Methods Retrospective review of consecutive patients undergoing thymectomy for an anterior mediastinal lesion at a single institution over a 13-year period. Preoperative clinical features were reviewed. Preoperative computed tomography (CT) scans were reviewed for features of the anterior mediastinal lesion, including mean attenuation, presence of calcification, lesion margins, and location. In some cases, fluorodeoxyglucose positron emission tomography (FDG-PET) was performed and SUV measured. Final histopathological diagnosis was reviewed. Non-therapeutic thymectomy was defined as a thymectomy for lymphoma or benign disease, in the absence of clinical features of myasthenia gravis. Results One hundred and five thymectomies were performed. Sixty-three thymectomies (60%) were performed for thymic neoplasm [thymoma (n=60) or thymic carcinoma (n=3)]. The rate of non-therapeutic thymectomy was 13% (n=14). Of the non-therapeutic thymectomy specimens, most were cystic lesions (n=6) and thymic hyperplasia (n=3). Mean CT attenuation of the lesions was higher overall in the therapeutic group versus the non-therapeutic group (52 vs. 23 HU, P<0.005). For resected thymomas, attenuation (HU 57) was higher compared to lesions in the non-therapeutic group: hyperplasia (18 HU, P<0.005), cysts (22 HU, P<0.005), benign thymic tissue (30 HU, P<0.005) and lymphoma (HU 41, P=0.009). Mean age of patients with thymoma was significantly higher than for age of patients with non-therapeutic resection of thymic hyperplasia (62 vs. 49 years, P=0.003). Twenty patients underwent FDG-PET scan (therapeutic group 15, non-therapeutic 5). There was no significant difference in FDG uptake between thymoma, and lesions in the non-therapeutic group. Of the non-therapeutic thymectomy group, none underwent preoperative magnetic resonance imaging (MRI). Conclusions The non-therapeutic thymectomy rate was 13%. Higher CT attenuation and higher age were significant differentiators of thymic neoplasm from benign pathology. Of the patients who underwent non-therapeutic thymectomy, none were investigated with preoperative MRI. FDG-PET did not differentiate thymoma from benign pathology. Attention to the above imaging and demographic features, and inclusion of MRI in the preoperative work up, may help reduce the rate of non-therapeutic thymectomy.

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