Effect of peri-operative intra-aortic balloon pump in patients undergoing coronary artery bypass grafting on outcomes in a resource limited setting.

INTRODUCTION: Intra-aortic balloon pump (IABP) insertion for diminished myocardial function is standard of care in cardiac surgery. Previous studies have suggested a possible benefit to IABP support before surgery with regards to outcomes and complications. However, there are conflicts with other studies suggesting no significant benefit. Optimal time of insertion, whether preoperative or perioperative (intra-operative and post-operative), has yet to be defined. METHODOLOGY: A retrospective, hospital records-based chart review was conducted for patients admitted to our center from January 2015 to December 2019 for coronary bypass surgery necessitating IABP insertion. Cases were stratified according to the timing of insertion and analyzed according to surgical outcomes and complication rates. RESULTS: Out of 97 patients, 84.5% underwent preoperative IABP insertion while 15.5% of patients received perioperative (Intra-operative or post-operative) insertion. In-hospital mortality was significantly higher in patients with perioperative IABP insertion as compared to the preoperative group (60% vs 20.7%, p = 0.003). However, there were no significant differences between 30-day readmission rates in the two groups (9.8% vs 6.7%, p = 1.000). Length of stay was also higher in patients with preoperative insertion of IABP (p = 0.032), with no significant difference in ICU stay (p = 0.107). Perioperative IABP patients had higher rates of arrhythmias (46.7%, p = 0.042) and reopening of patient (33.3%, p = 0.028). CONCLUSION: Our study shows improved mortality in patients with preoperatively inserted IABP. This may be beneficial for high-risk patients undergoing CABG surgery. Expanding the use of IABP before CABG in third world countries such as Pakistan may improve overall survival for patients.

Exploring the uncommon: A case report on localized peritonitis caused by ingested toothpick.

INTRODUCTION: Bowel perforation is a serious emergency. Occasionally, sharp objects like toothpicks can get stuck in narrow parts of the small intestine, potentially resulting in impaction, obstruction, or perforation. PRESENTATION OF CASE: A 20-year-old male arrived at our hospital's emergency department with sudden, severe abdominal pain persisting for 24 h. On examination, his abdomen showed tenderness, and bowel sounds were reduced. Contrast-enhanced computed tomography (CECT) indicated possible small intestine inflammation due to a foreign object and a diagnostic laparoscopy revealed a hyperemic terminal ileum. DISCUSSION: This case involves ileal perforation from an unnoticed toothpick ingestion. Detecting foreign object perforations is challenging, often leading to misdiagnoses and CT scans are the most effective for toothpick detection. Definitive diagnosis is through laparoscopy, and treatment varies between laparoscopic suturing to intestinal resection. CONCLUSION: Healthcare providers must consider toothpick ingestion in cases of acute abdominal symptoms to avert treatment delays and potential life-threatening outcomes.

COVID-19 pandemic and breast cancer management: A retrospective observational clinical study from Pakistan.

BACKGROUND: COVID-19 outbreak has adversely affected care of breast cancer patients world-wide. There is paucity of available data on cancer management in lower-middle income countries during this pandemic, we sought to determine the institutional approach towards management of breast cancer patients and the outcomes during COVID-19 pandemic at our institution. MATERIALS AND METHODS: Clinicopathological and treatment record of cancer patients who presented to the Breast Clinic from 15th March to 31st December 2020 was retrieved from the institutional database for this retrospective clinical observational study. RESULTS: A total of 292 patients were qualified for the analysis in which 206 patients (70.5%) underwent breast cancer surgeries. Only 10 of them (4.9%) were identified to be COVID-19 virus positive on routine pre-operative RT-PCR test before elective surgeries. All were asymptomatic, received home-based care via telecommunication and were operated at a later date when test turned out negative. None of them developed any complications post-operatively. Another group of 86 patients (29.5%) were referred for Neoadjuvant/Systemic chemotherapy in which COVID-19 infection was detected in only 4 patients (4.6%) while receiving cycles. Two patients shown symptoms of cough and fever hence hospitalised but were not candidates for Intensive Care Unit admission while other two patient were asymptomatic and isolated at home. All patients recovered well and chemotherapy was commenced again after negative RT-PCR test. No mortality was observed. CONCLUSION: Despite of being a global crisis particularly for cancer patients we observed infectivity, complications and fatality much lower among breast cancer cases. Further research is needed in this regard including public and private sector hospitals for better understanding behavior of COVID-19 disease and achieve common goal to combat COVID-19 and cancer together.

Wet labs: A useful tool in training surgical residents in a third world country.

•Wet labs are a useful, cost-effective and safe tool in teaching of Cardiothoracic Surgery residents.•In a third world country where advance real life simulators are not available.•It improves resident's tissue handling and surgical skills.•Allows faculty members to give continuous feedback to their residents.

Aberrant right subclavian artery with atrial septal defect: Simultaneous repair via median sternotomy.

INTRODUCTION: Aberrant right subclavian artery, also known as arteria lusoria, is one of the rarer congenital vascular malformations of the left sided aortic arch which arises distal to the left subclavian artery, following a retroesophageal course to the right side causing compression of the trachea or esophagus and resulting in a variety of symptoms most commonly dysphagia. PRESENTATION OF CASE: We report a case of a two and a half year old child who was diagnosed as having as having an aberrant right subclavian artery with an ostium secundum atrial septal defect and underwent simultaneous repair of both conditions via a median sternotomy. DISCUSSION: Aberrant right subclavian artery (ARSA) has a prevalence of 1.8 % and most commonly presents in fourth or fifth decade of life. Various surgical approaches have been described to repair this anomaly over the past years, each with its own limitations and complications. However, the median sternotomy approach provides adequate exposure during division and re-implantation of the vessel and simultaneously allows repair of any intra-cardiac defect. CONCLUSION: We believe that the best exposure for the correction of aberrant right subclavian artery is via a median sternotomy, especially in pediatric patients associated with other cardiac anomalies.

A rare case of constrictive pericarditis as initial manifestation of paediatric anaplastic large cell lymphoma requiring urgent pericardiectomy.

Constrictive pericarditis (CP) is a rare end stage inflammatory disorder affecting both parietal and visceral pericardium leading to a right heart failure. Malignancy is the least common cause of CP. Anaplastic large cell lymphoma (ALCL) accounts for 10-15% of all Non-Hodgkin lymphomas in children. Very few case reports have reported ALCL that is involving the heart and only two have been published involving pericardium but all were managed medically. We present an interesting case of an 11 year old child who presented with an effusive CP that required urgent Pericardiectomy for managing right heart failure. His histopathology was positive for ALK + ALCL.