Postoperative complications among dialysis-requiring patients undergoing splenectomy.

BACKGROUND: Dialysis patients are at high risk for surgery, but their outcomes after splenectomy are unclear. We compared postoperative complications between dialysis and non-dialysis patients. METHODS: Data were retrieved from the National Surgical Quality Improvement Program for this retrospective cohort. Adult patients undergoing elective splenectomy between 2005 and 2020 were included. RESULTS: Among 10,339 included patients, 143(1.4%) were on chronic dialysis. Postoperative mortality was higher in dialysis vs. non-dialysis patients (9.1% vs. 1.8%). Dialysis patients were more likely to have 30-day major morbidity, infectious and non-infectious complications, reoperation, and prolonged hospital stay. On multivariable regression, dialysis dependence significantly increased odds of mortality, major morbidity, blood transfusion, prolonged length of stay, reoperation, and failure-to-rescue (FTR). CONCLUSION: Dialysis patients were at higher risk of postoperative morbidity following splenectomy. Additionally, the risk of FTR in this patient population is also significantly more compared to non-dialysis patients.

Transforming surgical landscapes: obstacles in the integration of robotic surgery in Pakistan -is cost the only limiting factor?

The advantages of Robotic Assisted Surgery (RAS) over laparoscopic surgery encompass enhanced precision, improved ergonomics, shorter learning curves, versatility in complex procedures, and the potential for remote surgery. These benefits contribute to improved patient outcomes which have led to a paradigm shift in robotic surgery worldwide and it is now being hailed as the future of surgery. Robotic surgery was introduced in Pakistan in 2011, but widespread adoption has been limited. The future of RAS in Pakistan demands a strategic and comprehensive plan due to the substantial investment in installation and maintenance costs. Considering Pakistan's status as a low to middle-income country, a well-designed economic model compatible with the existing health system is imperative. The debate over high investments in robotic surgery amid unmet basic surgical needs underscores the complex dynamics of healthcare challenges in the country. In this review, we discuss the potential benefits of robotics over other surgical techniques, where robotic surgery stands in Pakistan and the possible hurdles and barriers limiting its use along with solutions to overcome this in the future.

Association of Metabolic Syndrome with Stroke, Myocardial Infarction, and Other Postoperative Complications Following Carotid Endarterectomy: A Multicenter, Retrospective Cohort Study.

BACKGROUND: Metabolic syndrome (MetS) is a constellation of hypertension, insulin resistance, obesity, and dyslipidemia and is known to increase the risk of postoperative morbidity. This study aimed to assess the impact of MetS on stroke, myocardial infarction, mortality, and other complications following carotid endarterectomy (CEA). METHODS: We analyzed data from the National Surgical Quality Improvement Program. Patients undergoing elective CEA between 2011 and 2020 were included. Patients with American Society of Anesthesiologists status 5, preoperative length of stay (LOS) > 1 day, ventilator dependence, admission from nonhome location, and ipsilateral internal carotid artery stenosis of < 50% or 100% were excluded. A composite cardiovascular outcome for postoperative stroke, myocardial infarction, and mortality was generated. Multivariable binary logistic regression analyses were used to assess the association of MetS with the composite outcome and other perioperative complications. RESULTS: We included 25,226 patients (3,613, 14.3% with MetS). MetS was associated with postoperative stroke, unplanned readmission, and prolonged LOS on bivariate analysis. On multivariable analysis, MetS was significantly associated with the composite cardiovascular outcome (1.320 [1.061-1.642]), stroke (1.387 [1.039-1.852]), unplanned readmission (1.399 [1.210-1.619]), and prolonged LOS (1.378 [1.024-1.853]). Other clinico-demographic factors associated with the cardiovascular outcome included Black race, smoking status, anemia, leukocytosis, physiologic risk factors, symptomatic disease, preoperative beta-blocker use, and operative time ≥ 150 min. CONCLUSIONS: MetS is associated with cardiovascular complications, stroke, prolonged LOS, and unplanned readmissions following CEA. Surgeons should provide optimized care to this high-risk population and strive to reduce operative durations.

Changes in patterns and outcomes of trauma patients after betterment in law and order situation of the city.

OBJECTIVE: To assess the impact of the law and order situation of a city on the pattern of traumatic injuries and the overall outcomes of trauma victims. METHODS: The retrospective study of prospective trauma surgery data was done at Aga Khan University Hospital, Karachi, and comprised data of patients with torso injuries before the improvement of law and order situation from January 2012 to March 2013 in Group A, and of those with similar injuries after the law and order situation improved in the city from January 2018 to March 2019 in Group B. The required data was collected by a single researcher using a predesigned questionnaire. Inter-group comparison was done to see the difference in patterns of injuries and outcomes. Data were analysed using SPSS 22. RESULTS: Of the 676 cases reviewed, Group A had 416(61.5%); 363(87%) males and 53(13%) females with overall mean age of 37±13 years. Group B had 260(38.5%); 219(84%) males and 41(16%) females with overall mean age of 36±13 years (p>0.05). Penetrating trauma alone or combined with blunt force was the most common mechanism in Group A i.e. 245 (59%) patients, while in group B blunt trauma was the commonest cause 209 (80.4%) patients. There was an overall 156 (37.5%) cases reduction in torso trauma cases. Mortality in Group A was 22(5.3%) and in Group B it was 7(2.7%). CONCLUSIONS: With the improvement in the law and order situation, there was reduction in overall trauma cases and the pattern of trauma shifted from penetrating to blunt injuries.

Bone marrow aplasia in Haemophilia-A with Hepatitis-C and human immunodeficiency virus co-infection: A case report.

Haemophilia A is an inherited bleeding disorder caused due to the deficiency of factor VIII. This case report of a 17-year-old HA boy co-infected by hepatitis C (HCV) and human immunodeficiency virus (HIV) followed by bone marrow aplasia seeks to address the key clinical question of the causality and management of bone marrow aplasia in a resource-constrained setting. Our patient developed pancytopenia which prompted the diagnosis and management of HCV and HIV. Bone marrow biopsy revealed severe aplasia. He was treated with highly active antiretroviral therapy (HAART). Two years later, he developed septic arthritis and haemarthrosis of the elbow and knee joints. He underwent arthrotomy of the knee joint. The patient expired, postoperatively, due to septic shock. This case underlines the need for truly universal access to virally inactivated replacement therapy to prevent complications secondary to infections transmitted by transfusion.

In a digitally connected world through Likes, Hashtags and Followers - Advancing surgical research through a social media: A narrative review.

In this era of modern information technology, the world is now digitally connected through various platforms on social media, which has changed the way medical professionals work, communicate and learn. The use of social media in surgery is expanding, and it is now becoming an essential tool for surgical training, research and networking. Articles, journal clubs and surgical conferences are within reach of everyone regardless of geographical location worldwide. Electronic publications have now resoundingly replaced printed editions of journals. Collaborative research through social media platforms helps collect diverse data, enhancing the research's global generalisability. The current narrative review was planned to discuss the importance of social media in advancing surgical research and the use of different social media applications in the context of promoting and disseminating surgical research alongside its evolving ethical challenges.

Assessment of Trauma Care Capacity in Karachi, Pakistan: Toward an Integrated Trauma Care System.

BACKGROUND: Pakistan is a lower-middle-income country with a high burden of injuries. Karachi, its most populated city, lacks a trauma care system due to which trauma patients do not receive the required care. We conducted an assessment of the existing facilities for trauma care in Karachi. METHODS: Twenty-two tertiary and secondary hospitals from public and private sectors across Karachi were assessed. The Guidelines for Essential Trauma Care (GETC) tool was used to collect information about the availability of skills, knowledge, and equipment at these facilities. RESULTS: Among tertiary hospitals (n = 7), private sector hospitals had a better median (IQR) score, 90.4 (81.8-93.1), as compared to the public sector hospitals, 44.1 (29.3-75.8). Among secondary hospitals (n = 15), private sector hospitals had a better median (IQR) score, 70.3 (67.8-77.7), as compared to the public sector hospitals, 39.7 (21.9-53.3). DISCUSSION: This study identifies considerable deficiencies in trauma care in Karachi and provides objective data that can guide urgently needed reforms tailored to this city's needs. On a systems level, it delineates the need for a regulatory framework to define trauma care levels and designate selected hospitals across the city accordingly. Using these data, improvement in trauma care systems can be achieved through collaboration and partnership between public and private stakeholders.

Demonstrating competence in Endoscopic Retrograde Cholangiopancratico graphy (ERCP): Recently credentialed operator's performance for deep biliary cannulation over 1 year period from a tertiary care hospital in Pakistan.

OBJECTIVE: To measure the success rate of endoscopic retrograde cholangiopancreaticography biliary cannulation of a recently credentialed endoscopist at a tertiary hospital. METHODS: The clinical audit was conducted at the Aga Khan University Hospital. Karachi, and comprised data of all patients who underwent endoscopic retrograde cholangiopancreaticography under the care of a single operator during 2016. Data was retrospectively extracted from patient charts by an assistant blinded to the study. Data extracted included demographics, admission type, details and indication for the procedure, diagnosis, cannulation outcome, duct clearance, complications, follow-up surgical intervention, radiological imaging and mortality post-endoscopy. Data was analysed using SPSS 19. RESULTS: Of 143 procedures performed, 102(71.3%) were included. The mean age was 52±17 years and 54(52.9%) of them were females. Most common indication was choledocholithiasis in 70(68.6%). The average procedure time was 41.5±5.5 minutes. Cannulation success rate was 96(94.1%). Complications included post-procedure pancreatitis in 5(4.9%), minimal bleeding in 8(7.8%) and oesophageal perforation in 1(0.98%). There was no procedure-related mortality. CONCLUSIONS: The success rate was high and complications were low with zero mortality.

Impact of a global pandemic on surgical education and training- review, response, and reflection.

The catastrophic effects of the coronavirus disease-2019 global pandemic have revolutionised human society. The unprecedented impact on surgical training needs to be analysed in detail to achieve an understanding of how to deal with similar situations arising in the foreseeable future. The challenges faced by the surgical community initiated with the suspension of clinical activities and elective practice, and included the lack of appropriate personal protective equipment, and the self-isolation of trainees and reassignment to coronavirus patient-care regions. Together, all these elements had deleterious effects on the psychological health of the professionals. Surgical training irrespective of specialty is equally affected globally by the pandemic. However, the global crisis inadvertently has led to a few constructive adaptations in healthcare systems, including the development of tele-clinics, virtual academic sessions and conferences, and increased usage of simulation. The current review article was planned to highlight the impact of corona virus disease on surgical training and institutions' response to the situation in order to continue surgical training, and lessons learnt from the pandemic.

Gastric volvulus in adults in a tertiary care hospital Karachi, Pakistan: A case series.

Gastric volvulus is a rare surgical emergency which is rare in children and occasionally presents in adults. It results due to pathological malrotation of the stomach along its longitudinal or short axis. The condition, if not treated promptly, can result in increased morbidity and carries a high risk of death. Very few cases have been reported in literature regards this important clinical condition. Early decompression and repair of anatomical defects are the corner stone of its management. There is a dire need to develop guidelines and algorithms for management and treatment of this rare condition to improve patient outcome, prevent recurrence and facilitate early diagnosis by practicing physicians and surgeons. We report three such cases which presented to our setup in emergency along with a brief description of how they were successfully managed.

Impact of time of arrival in emergency unit on estimation of injuries and overall care of trauma victims.

BACKGROUND: Outcomes of trauma victims largely depends upon available resources, not only in terms of location of high level trauma center near the area where incident takes place but also on staff and equipment available at that particular center at that particular time. This study used retrospective charts review to ascertain whether trauma patients presenting during the night time would have delayed in establishing injuries after necessary investigations and higher in-hospital mortality than those trauma patients arriving during the day time at our hospital. METHODS: This was a cross sectional study, conducted in department of Surgery, Aga Khan University Hospital, Karachi. Data was obtained from patients charts by a single investigator. By random sampling technique, 146 patients admitted between 1st January 2018 to 31st December 2018inthe Emergency Department of the Aga Khan University Hospital, Karachi were included. Patients were placed into two groups. Those arriving in hospital from 7 am to 7 pm were labeled as day time group while those who presented from 7 pm to 7 am were labeled as night time group. Difference in mortality in each group and time required for carrying out investigations and admissions to definite care were recorded and compared among both groups. RESULTS: A total of 146 patient charts were reviewed, with 73 patients each in both day time (DT) and night time (NT) groups. Out of 146 trauma victims 123(82.2%) were male and 23(17.8%) were female. Mean age in our population was 37.4 years (±14.3). Road traffic accident (RTA) was the most common cause in 121 patients (82.9%). Time required to conduct trauma services was shorter and significant in DT group as compared to NT group. There was significant difference observed in time required for admission in each group, with mean of 6hours and 40 minutes ± 4 hours,22 minutes in DT group and 8 hours, 36 minutes (± 5 hours,11 minutes in NT group (p = 0.03). However there was no significant difference in mortality observed in both groups. CONCLUSIONS: In our hospital time of arrival has no impact on overall mortality of trauma patients. However time to carryout necessary investigations for stable trauma patients and their admissions to definite care is longer as compared to day time arrival of emergency trauma patients.

Management of early rectal cancer: Current practice and future.

Early rectal cancer management includes tumour stages TiS, T1 and some selected T2 lesions that undergo appropriate clinical pre-operatie evaluation. Local excision of these lesions with acceptable recurrence rate can be achieved through various transanal endoscopic techniques like transanal endoscopic microsurgery (TEM) and transanal minimal invasive surgery (TAMIS) that are superior to simple transanal excision (TAE). The current literature review was planned to present the oncological evaluation of local excision in the context of available evidence. An overview of perioperative adjuvant therapies employed along with local excision is presented, with an update on the latest trials.

Developing a low budget trauma registry.

Trauma registry plays an essential role in collecting epidemiological injury data which is used in quality care improvement and research. This paper was planned toshare our experience of having developed a low-budget user-friendly trauma registry with the help of Microsoft Access. This was used because of its ease of use, quickdevelopment style, and support for relational database d esign. Var iable i nc lud ed in our registr y were demographics, description of injury, International Classification of Disease 9 Clinical Modification (ICD9- CM) external injury classification codes, date and time of arrival, length of hospital stay, referral to and from hospital, physiological assessment along with scores for assessing the injury severity. Developing a local trauma registry helped us in scrutinising our practice, and we believe that a national or regional trauma registry is the need of the hour in Pakistan. This will highlight the concerns specific to our society in providing quality trauma care.

Is pelvis x-ray essential in stable trauma patients? Step towards lowering the treatment cost.

OBJECTIVE: To determine the diagnostic accuracy of clinical examination in detecting pelvic fractures in patients with blunt trauma.. METHODS: The cross-sectional prospective study was conducted at Aga Khan University Hospital, Karachi, from January to June 2015, and comprised alert, awake blunt-trauma patients. Pelvis examination findings were compared to routine pelvic X-rays. SPSS 19 was used for data analysis.. RESULTS: Of the 133 patients, 122 (92%) were males. Overall mean age was 37 ±14.2 years. There were 14 (10%) patients who were true positives with pelvic fracture diagnosis on both clinical examination and pelvic X-ray, while 14 (10%) were false negative on examination. Clinical examination missed 2 patients with evidence of fracture on X-ray and were considered false positive. Besides, 103 (77.4%) patients were true negative as both clinical exam and X-ray showed no evidence of fracture. CONCLUSION: Omitting pelvic X-ray in the recommended protocol can avoid unnecessary financial burden and reduce undesirable radiation exposure..

Better outcome of splenectomy in younger patients suffering from chronic immune thrombocytopenia (ITP).

Immune thrombocytopenia purpura (ITP) may need splenectomy after failure of medical treatment. The aim of this study was to explore the outcome of splenectomy in chronic ITP and to point out factors which can predict better response to splenectomy. This retrospective chart review was conducted at the Aga Khan University Hospital, Karachi, and comprised adult patients who underwent splenectomy for ITP from October 2005 to December 2015. Of the 51 patients, 37(72.5%) were females and 14(27.5%) were males. The overall median age was 32 years (interquartile range: 18-65 years). Complete response was seen in 43(84.3%) patients, 2(4%) had response and 6(11.7%) had no response. Relapse rate of ITP at 1 year was 4(8.8%). Multivariate analysis showed that failure rate of splenectomy in the 41(80.4%) patients aged <50 years was 3(7%) as opposed to 3(30%) in the 10(19.6%) patients aged >50 years (p=0.04). Splenectomy was found to be a safe and effective option for treatment of ITP. Young age at the time of surgery was associated with good response to surgery.

Abdominal gunshot wounds-a comparative assessment of severity measures.

BACKGROUND: Penetrating abdominal trauma is a common feature of trauma treated in low- and middle-income countries (LMICs). The penetrating abdominal trauma index (PATI) and the injury severity score (ISS) are severity-measures most often used to gauge injury severity. It remains unclear which measure better accounts for the severity of sustained injuries. This study compares the predictive ability of both injury severity measures in patients presenting to an LMIC in South Asia. METHODS: All isolated gunshot wounds to the abdomen presenting to a university hospital between 2011 and 2012 were included. ISS and PATI were calculated for each case. Primary outcome measures included all-cause mortality and complications. Multivariable analysis adjusting for age, sex, referral status, hypotension, tachycardia, and injury severity measures was performed. The area under the receiver operating characteristic (AUROC) curve were further calculated to compare the respective abilities of ISS and PATI at predicting death and complications. RESULTS: A total of 70 patients were included. The average age on presentation was 34.5 y (±11.4) within a predominantly male (n = 68, 97.1%) cohort. Most gunshot wounds were intentionally inflicted (n = 67, 95.7%). The crude rates of death and complications were 34.3% and 15.7%, respectively. The median ISS was 14 (interquartile range: 11-21), and the median PATI was 16 (interquartile range: 9-26). AUROC analysis revealed that ISS was comparable with PATI at predicting mortality (AUROC [95% confidence interval]: 0.952 [0.902-1.00] versus 0.934 [0.860-1.00]) and complications (AUROC [95% confidence interval]: 0.868 [0.778-0.959] versus 0.895 [0.815-0.975]). CONCLUSIONS: The predictive ability of ISS and PATI severity measures was found to be comparable. The results suggest that both measures can be used to risk-stratify patients with isolated abdominal gunshot wounds in an LMIC.

Inter-facility transfer of surgical emergencies in a developing country: effects on management and surgical outcomes.

OBJECTIVES: Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters. METHODS: We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (non-transfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests. RESULTS: Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was "lack of satisfactory surgical care." There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values <0.001) between transferred and non-transferred patients. In 56 patients there was a further delay in admission, and the most common reason was bed availability, followed by financial constraints. Three patients were shifted out of the hospital due to lack of ventilator, and 14 patients left against medical advice due to financial limitations. One patient died. CONCLUSIONS: Inter-facility transfer of patients with surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.

Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB).

BACKGROUND: National trauma registries have helped improve patient outcomes across the world. Recently, the idea of an International Trauma Data Bank (ITDB) has been suggested to establish global comparative assessments of trauma outcomes. The objective of this study was to determine whether global trauma data could be combined to perform international outcomes benchmarking. METHODS: We used observed/expected (O/E) mortality ratios to compare two trauma centers [European high-income country (HIC) and Asian lower-middle income country (LMIC)] with centers in the North American National Trauma Data Bank (NTDB). Patients (≥16 years) with blunt/penetrating injuries were included. Multivariable logistic regression, adjusting for known predictors of trauma mortality, was performed. Estimates were used to predict the expected deaths at each center and to calculate O/E mortality ratios for benchmarking. RESULTS: A total of 375,433 patients from 301 centers were included from the NTDB (2002-2010). The LMIC trauma center had 806 patients (2002-2010), whereas the HIC reported 1,003 patients (2002-2004). The most important known predictors of trauma mortality were adequately recorded in all datasets. Mortality benchmarking revealed that the HIC center performed similarly to the NTDB centers [O/E = 1.11 (95% confidence interval (CI) 0.92-1.35)], whereas the LMIC center showed significantly worse survival [O/E = 1.52 (1.23-1.88)]. Subset analyses of patients with blunt or penetrating injury showed similar results. CONCLUSIONS: Using only a few key covariates, aggregated global trauma data can be used to adequately perform international trauma center benchmarking. The creation of the ITDB is feasible and recommended as it may be a pivotal step towards improving global trauma outcomes.

Outcomes of splenectomy for idiopathic thrombocytopenic purpura in adults: a developing country perspective.

OBJECTIVE: To determine the outcome of splenectomy done in adult patients of Idiopathic Thrombocytopenic Purpura over a period of 10 years and, secondarily, to determine the predictors of complete response to therapy. METHODS: The retrospective review comprised of adult patients over 14 years of age who underwent open or laparoscopic splenectomy for Idiopathic Thrombocytopenic Purpura at Aga Khan University Hospital, Karachi, from January 2000 to December 2010. Data was reviewed in January 2011 by a surgical resident. Outcome was the response to splenectomy as per new definition of response set by the American Society of Haematology 2011 evidence based practice guidelines for Idiopathic Thrombocytopenic Purpura. Assessment of response was done within 1 to 2 months of splenectomy and after withholding concomitant treatment. SPSS 17 was used for statistical analysis. RESULTS: A total of 27 patients were found eligible. Of them, 2 (7.4%) were males and 25 (92.6%) were females with an overall mean age at the time of splenectomy of 30.8±6.3 years (range: 15-55 years). Out of 27 cases, 23 (85.18%) patients underwent open splenectomy, 3 (11%) laparoscopic and 1 (3.7%) had laparoscopic converted to open splenectomy. Complete response was achieved in 20 (74.1%) patients, whereas 5 (18.5%) had response and 2 (7.4%) had no response. None of the predictors of response to splenectomy were found significant. CONCLUSION: Response to splenectomy in adult Idiopathic Thrombocytopenic Purpura patients was comparable to reported rate in literature with relatively lower morbidity and mortality. Splenectomy is a safe treatment option especially in patients who succumb to adverse effects of medical therapy.