Innovations in surgery between the past and future: A narrative review of targeted literature

Innovation is the introduction of a new method or technology designed to change the way things are done. History is full of remarkable innovations in surgery over the years as surgeons have always been innovating and pioneering latest techniques and equipment that can benefit the mankind. Though persistent, progress has been far from uniform. Despite all the bells and whistles that these innovations bring to the table, the little acknowledged fact is that they are only accessible to a very small proportion of the global population. Five billion people on this planet do not even have access to an operating room when needed. It has been reported that conditions requiring surgery are responsible for one-third of all the deaths in the world. The current narrative review was planned to focus on the importance of innovations in surgery, to highlight the problems that were faced by resource-restricted countries in the past, and the necessity of innovative solutions to improve global surgical care in the future

Radial artery coronary bypass grafting: Surgical outcomes of an unexplored innovation in a developing country

Objective: To explore postoperative outcomes, particularly prolonged length of hospital stay, in radial artery coronary artery bypass graft patients in a tertiary-care setting. Methods: The pilot prospective cohort study was conducted at the Aga Khan University Hospital, Karachi, from September 2019 to September 2020, and comprised adult patients of either gender due to undergo coronary artery bypass grafting for coronary artery disease involving two or more vessels. The subjects were approached for the use of their radial artery as a conduit. Prolonged length of hospital stay was defined as postoperative stay \u3e9 days. Multivariable logistic regression was used to identify independent predictors of the length of hospital stay. Data was analysed using SPSS 21. Results: Of the 97 patients, 84(86.6%) were males. The overall mean age of the sample was 58.33±8.34 years. Mean length of hospital stay was 8.10±2.37 days, and 23(23.7%) patients had prolonged stay. Higher age was a significant predictor of prolonged hospital stay (p\u3c0.05). Besides, 23(23.7%) patients developed acute kidney injury. There was no incidence of wound, infection or deep venous thrombosis, while 1(1.03%) patient had to be reopened due to excessive postoperative bleeding, and it represented the lone mortality. Conclusions: Patient age was found to be a significant predictor of prolonged hospital stay in patients undergoing radial artery coronary artery bypass graft, while almost a quarter of the sample was affected by acute kidney injury

Major septal defects: Comparative study of down syndrome and non-down syndrome infants, before and after surgery

Objective: To compare pre-operative, intra-operative, and post-operative parameters in Down syndrome (DS) and non-DS patients with atrioventricular septal defects (AVSD) and inlet ventricular septal defects (VSD) in a tertiary care hospital in Pakistan.Methods: We conducted a retrospective study at Aga Khan University, Pakistan. All complete atrioventricular septal defect (CAVSD), partial atrioventricular septal defect (PAVSD), and VSD with inlet extension surgical cases from January 2007 to January 2019 were included. Patients with congenital heart diseases other than those listed above were excluded.Results: In 61 cases, 18 had DS. Median age, mean body surface area (BSA), and height were lower in DS patients compared to non-DS patients: 7.0 vs 23.0 months, 0.311 vs 0.487 m2, and 63 vs 82 cm, respectively. Bypass duration, aortic cross clamp time, post-operative ventilator hours, dose of inotropes, CICU stay, and total hospital stay were all significantly higher in the DS group. The odds ratio (955% CI) for mortality in DS babies was 6.2 (1.4, 27.1), p=0.015, after adjusting for age, weight, and height. The overall morbidity was comparable between the two groups, demonstrating no significant difference after adjusting for confounders.Conclusion: DS babies with AVSD and inlet VSD are at a greater risk of mortality compared to non-DS babies, particularly those with CAVSD. Furthermore, DS babies undergo surgery at a younger age and require more aggressive post-operative therapy and monitoring due to the development of complications

An audit of contrast extravasation in patients undergoing contrast enhanced CTs at radiology department in a tertiary care hospital in Pakistan

Objective: To audit the radiology department of a health facility, focusing on contrast extravasations management pre- and post-implementation of a standard protocol. Methods: The audit was conducted at the Radiology Department of Shifa International Hospital, Islamabad, Pakistan and comprised reported computed tomography contrast extravasation incidents from January 2017 to December 2019 in the retrospective phase before the implementation of a standard protocol. Post-implementation, re-audit was done prospectively to assess compliance from January 2020 to May 2021. Overall score of >80% was chosen arbitrarily as a qualifying standard for adequate documentation. Results: Of the 49 total cases, 26(53%) related to the first phase and 23(47%) to the second. In the first phase, 2(20%) of the 10 parameters cleared the cut-off mark; 'study performed' 25(96%) and 'limb assessment by technician' 26(100%). In the second phase, 2(20%) parameters failed to clear the cut-off mark; site of cannula/extravasation' 18(78.3%) and 'volume of contrast' 15(65%). Conclusion: Lack of early identification and appropriate management, especially in cases of large-volume extravasation, may result in significant morbidity. Key Words: Contrast extravasation, Contrast-enhanced CT, IV contrast media

Leveraging clinical digitized data to understand temporal characteristics and outcomes of acute myocardial infarctions at a tertiary care medical centre in Pakistan from 1988-2018 - Methods and results

Background and objective: Few data exist on trends in acute myocardial infarction (AMI) patterns spanning recent epidemiological shifts in low middle-income countries (LMICs). To understand temporal disease patterns of AMI characteristics and outcomes between 1988-2018, we used digitized legacy clinical data at a large tertiary care centre in Pakistan.Methods: We reviewed digital health information capture systems maintained across the Aga Khan University Hospital and obtained structured elements to create a master dataset. We included index admissions of patients \u3e18 years that were discharged between January 1, 1988, and December 31, 2018, with a primary discharge diagnosis of AMI (using ICD-9 diagnoses). The outcome evaluated was in-hospital mortality.Clinical characteristics derived from the electronic database were validated against chart review in a random sample of cases (k 0.53-1.00).Results: The final population consisted of 14,601 patients of which 30.6% (n = 4,470) were female, 52.4% (n = 7,651) had ST elevation MI and 47.6% (n = 6,950) had non-ST elevation MI. The median (IQR) age at presentation was 61 (52-70) years. Overall unadjusted in-hospital mortality was 10.3%. Across the time period, increasing trends were noted for the following characteristics: age, proportion of women, prevalence of hypertension, diabetes, proportion with NSTEMI (all ptrend \u3c 0.001). In-hospital mortality rates declined significantly between 1988-1997 and 2008-2018 (13.8% to 9.2%, p \u3c 0.001).Conclusions: The patterns of AMI have changed over the last three decades with a concomitant decline in in-hospital mortality at a tertiary care centre in Pakistan. Clinical digitized data presents a unique opportunity for gaining insights into disease patterns in LMICs