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Aruparayil N, Gnanaraj J, Mishra A, Bains L, Corrigan N, Brown J, Ensor T, King R, Shinkins B, Jayne D. Gasless laparoscopy in rural India-registry outcomes and evaluation of the learning curve. Surg Endosc 2023; 37:8227-8235. [PMID: 37653156 PMCID: PMC10615921 DOI: 10.1007/s00464-023-10392-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/13/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND A program of gasless laparoscopy (GL) has been implemented in rural North-East India. To facilitate safe adoption, participating rural surgeons underwent rigorous training prior to independent clinical practice. An online registry was established to capture clinical data on safety and efficacy and to evaluate initial learning curves for gasless laparoscopy. METHODS Surgeons who had completed the GL training program participated in the online RedCap Registry. Patients included in the registry provided informed consent for the use of their data. Data on operative times, conversion rates, perioperative complications, length of stay, and hospital costs were collected. Fixed reference cumulative sum (CUSUM) model was used to evaluate the learning curve based on operative times and conversion rates published in the literature. RESULTS Four surgeons from three rural hospitals in North-East India participated in the registry. The data were collected over 12 months, from September 2019 to August 2020. One hundred and twenty-three participants underwent GL procedures, including 109 females (88.6%) and 14 males. GL procedures included cholecystectomy, appendicectomy, tubal ligation, ovarian cystectomy, diagnostic laparoscopy, and adhesiolysis. The mean operative time was 75.3 (42.05) minutes for all the surgeries. Conversion from GL to open surgery occurred in 11.4% of participants, with 8.9% converted to conventional laparoscopy. The main reasons for conversion were the inability to secure an operative view, lack of operating space, and adhesions. The mean length of stay was 3 (2.1) days. The complication rate was 5.7%, with one postoperative death. The CUSUM analysis for GL cholecystectomy showed a longer learning curve for operative time and few conversions. The learning curve for GL tubal ligation was relatively shorter. CONCLUSION Gasless laparoscopy can be safely implemented in the rural settings of Northeast India with appropriate training programs. Careful case selection is essential during the early stages of the surgical learning curve.
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Affiliation(s)
- N Aruparayil
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK.
- St. James's University Hospital, Level 7, Clinical Sciences Building, Leeds, LS9 7TF, UK.
| | | | - A Mishra
- Maulana Azad Medical College, Delhi, India
| | - L Bains
- Maulana Azad Medical College, Delhi, India
| | - N Corrigan
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - J Brown
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - T Ensor
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - R King
- Nuffield Centre for International Health and Development, University of Leeds, Leeds, UK
| | - B Shinkins
- Academic Unit of Health Economics, University of Leeds, Leeds, UK
- Division of Health Sciences, University of Warwick, Coventry, UK
| | - D Jayne
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
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2
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Webb MM, Bridges P, Aruparayil N, Chugh C, Beacon T, Singh T, Sawhney SS, Bains L, Hall R, Jayne D, Gnanaraj J, Mishra A, Culmer PR. The RAIS Device for Global Surgery: Using a Participatory Design Approach to Navigate the Translational Pathway to Clinical Use. IEEE J Transl Eng Health Med 2022; 10:3700212. [PMID: 35865752 PMCID: PMC9292337 DOI: 10.1109/jtehm.2022.3177313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/10/2022] [Accepted: 05/17/2022] [Indexed: 11/19/2022]
Abstract
Background: Over 5 billion people worldwide have no access to surgery worldwide, typically in low-resource settings, despite it being a primary life-saving treatment. Gas Insufflation-Less Laparoscopic Surgery (GILLS) can address this inequity, by improving current GILLS instrumentation to modern surgical standards. Objective: to develop and translate a new Retractor for Abdominal Insufflation-less Surgery (RAIS) into clinical use and thus provide a context-appropriate system to advance GILLS surgery. Methods: A collaborative multidisciplinary team from the UK and India was formed, embedding local clinical stakeholders and an industry partner in defining user and contextual needs. System development was based on a phased roadmap for ‘surgical device design in low resource settings’ and embedded participatory and frugal design principles in an iterative process supported by traditional medical device design methodologies. Each phase of development was evaluated by the stakeholder team through interactive workshops using cadaveric surgical simulations. A Commercialisation phase undertook Design to Manufacture and regulatory approval activities. Clinical validation was then conducted with rural surgeons performing GILLS procedures using the RAIS system. Semi-structured questionnaires and interviews were used to evaluate device performance. Results: A set of user needs and contextual requirements were defined and formalised. System development occurred across five iterations. Stakeholder participation was instrumental in converging on a design which met user requirements. A commercial RAIS system was then produced by an industry partner under Indian regulatory approval. This was successfully used in clinical validation to conduct 12 surgical procedures at two locations in rural India. Surgical feedback showed that the RAIS system provided a valuable and usable surgical instrument which was appropriate for use in low-resource contexts. Conclusions: Using a context-specific development approach with close engagement of stakeholders was crucial to develop the RAIS system for low-resource regions. The outcome is translation from global health need into a fully realized commercial instrument which can be used by surgeons in low-resource regions across India.
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Affiliation(s)
- M. Marriott Webb
- School of Mechanical Engineering, University of Leeds, Leeds, U.K
| | | | - N. Aruparayil
- Leeds Institute of Medical Research, University of Leeds, Leeds, U.K
| | - C. Chugh
- Department of Surgery, Maulana Azad Medical College, New Delhi, India
| | - T. Beacon
- Medical Aid International, Bedford, U.K
| | - T. Singh
- XLO Ortho Life Systems, New Delhi, India
| | | | - L. Bains
- Department of Surgery, Maulana Azad Medical College, New Delhi, India
| | - R. Hall
- Pd-m International, Thirsk, U.K
| | - D. Jayne
- Department of Academic Surgery, University of Leeds, Leeds, U.K
| | - J. Gnanaraj
- Department of Electronics and Instrumentation Engineering, Karunya University, Coimbatore, India
| | - A. Mishra
- Department of Surgery, Maulana Azad Medical College, New Delhi, India
| | - P. R. Culmer
- School of Mechanical Engineering, University of Leeds, Leeds, U.K
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Gnanaraj J, Sindhu E, Nandakumaran M, Veeramani R, Kannan K, Anne Princy S, Cecily Mary M, Arumugam MA, Kannan P, Sabapathy K, Swaminathan N, Senthil Kumar G, Nambirajan N, Balasubramanian T, Ravichandran Edwin JM. Impact of COVID-19 pandemic on a developing STEMI care system from a low-middle income country- a prospective observational study. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
COVID-19 pandemic has produced a great impact in the STEMI (ST Elevation Myocardial Infarction) care systems across the world. Patient hesitancy to seek medical attention for suspected STEMI, necessity of the health care systems to prioritize COVID-19 care, safety concerns of health care workers etc., have brought in unprecedented times for both patients and health care workers. The impact of COVID-19 pandemic on the establishment of a STEMI care system is less known
Purpose
To identify the impact of COVID-19 pandemic on a developing public STEMI care system in a low-middle income country in Asia, with reference to the type of reperfusion offered and outcome.
Methods
Data on number of STEMI admissions, type of reperfusion therapy and outcome are being collected from 12 teaching hospitals as a part of a developing public regional STEMI care system based on a hub and spoke model in a low middle-income country from August 2018. These 12 “thrombolysis only” hospitals were being upgraded as “primary percutaneous coronary intervention (PPCI) capable hub hospitals” in 2019. Though the hassles of COVID-19 pandemic affected this process significantly, daily data collection in our STEMI care system continued. The maximal COVID impacted period in 2020 was identified from the online database (1) as from April to December 2020. The number, type of reperfusion and outcome of the STEMI patients treated during this period were compared to the same data collected during April-December 2019.
Results
A total of 13,137 STEMI patients were treated in our system during the two time periods “April to December 2019” and “April to December 2020”. There was a 13.3% drop in the number of STEMI treated in 2020, compared to the number treated in 2019 (6101 vs 8925; P<0.001). This drop was in proportion to the number of new cases of COVID-19 reported in our state (Fig. 1a)
We also noted a significant drop in the rate of PPCI and Pharmaco-invasive therapy (PIT) offered for STEMI in 2020 compared to 2019 in the same period (PPCI: 0.13% vs 5.9%-P<0.001 and PIT 0.64% vs 11%- P<0.001). This decrease in PPCI and PIT for STEMI also corresponded to the increase in number of new cases of COVID-19 reported (Fig. 1b). More patients received thrombolytic therapy for STEMI in 2020 compared to 2019 (73.6 vs 61.2% P<0.001). There was no change in the mortality of STEMI during this period. (Fig. 2)
Conclusion
We found a significant drop in number of patients seeking medical care for STEMI during COVID-19 pandemic. There was significant drop in the rate of PPCI and PIT offered in our STEMI care system. Thrombolytic therapy remained the predominant mode of reperfusion as before, but with a significant increased rate of thrombolysis. There was no change in mortality rate in STEMI patients. Thrombolytic therapy is an acceptable mode of reperfusion, when the balance of a STEMI care system is disturbed by extraneous influences like the COVID-19 pandemic.
Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): Tamil Nadu Innovation Initiative- Department of Planning and development, Govt of Tamil NaduNational Health Mission, Government of India
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Affiliation(s)
| | - E Sindhu
- Madras Medical College, Chennai, India
| | | | | | - K Kannan
- Stanley Medical College, Chennai, India
| | - S Anne Princy
- Tamil Nadu Government Multi Super Speciality Hospital, Chennai, India
| | - M Cecily Mary
- Tamil Nadu Government Multi Super Speciality Hospital, Chennai, India
| | - M A Arumugam
- Chengalpattu Medical College, Chengalpattu, India
| | - P Kannan
- Governnment MKM Medical College, Salem, India
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Aruparayil N, Bolton W, Mishra A, Bains L, Gnanaraj J, King R, Ensor T, King N, Jayne D, Shinkins B. Clinical effectiveness of gasless laparoscopic surgery for abdominal conditions: systematic review and meta-analysis. Surg Endosc 2021; 35:6427-6437. [PMID: 34398284 PMCID: PMC8599349 DOI: 10.1007/s00464-021-08677-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND In high-income countries, laparoscopic surgery is the preferred approach for many abdominal conditions. Conventional laparoscopy is a complex intervention that is challenging to adopt and implement in low resource settings. This systematic review and meta-analysis evaluate the clinical effectiveness of gasless laparoscopy compared to conventional laparoscopy with CO2 pneumoperitoneum and open surgery for general surgery and gynaecological procedures. METHODS A search of the MEDLINE, EMBASE, Global Health, AJOL databases and Cochrane Library was performed from inception to January 2021. All randomised (RCTs) and comparative cohort (non-RCTs) studies comparing gasless laparoscopy with open surgery or conventional laparoscopy were included. The primary outcomes were mortality, conversion rates and intraoperative complications. SECONDARY OUTCOMES operative times and length of stay. The inverse variance random-effects model was used to synthesise data. RESULTS 63 studies were included: 41 RCTs and 22 non-RCTs (3,620 patients). No procedure-related deaths were reported in the studies. For gasless vs conventional laparoscopy there was no difference in intraoperative complications for general RR 1.04 [CI 0.45-2.40] or gynaecological surgery RR 0.66 [0.14-3.13]. In the gasless laparoscopy group, the conversion rates for gynaecological surgery were high RR 11.72 [CI 2.26-60.87] when compared to conventional laparoscopy. For gasless vs open surgery, the operative times were longer for gasless surgery in general surgery RCT group MD (mean difference) 10 [CI 0.64, 19.36], but significantly shorter in the gynaecology RCT group MD - 18.74 [CI - 29.23, - 8.26]. For gasless laparoscopy vs open surgery non-RCT, the length of stay was shorter for gasless laparoscopy in general surgery MD - 3.94 [CI - 5.93, - 1.95] and gynaecology MD - 1.75 [CI - 2.64, - 0.86]. Overall GRADE assessment for RCTs and Non-RCTs was very low. CONCLUSION Gasless laparoscopy has advantages for selective general and gynaecological procedures and may have a vital role to play in low resource settings.
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Affiliation(s)
- N Aruparayil
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK. .,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK.
| | - W Bolton
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - A Mishra
- Maulana Azad Medical College, Delhi, India
| | - L Bains
- Maulana Azad Medical College, Delhi, India
| | | | - R King
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - T Ensor
- Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - N King
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - D Jayne
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
| | - B Shinkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.,NIHR Global Health Research Group, Surgical Technologies, Clinical Sciences Building, Level 7, Room 7.19, Leeds, LS9 7TF, UK
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Wilkinson E, Aruparayil N, Gnanaraj J, Jayne D. 337 Barriers to Laparoscopic Surgical Training for Abdominal Conditions in Low- and Middle-Income Countries (LMICS): A Systematic Review. Br J Surg 2021. [DOI: 10.1093/bjs/znab134.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Introduction
Resource-deprived low-and-middle-income countries (LMICs) can benefit from the reduced perioperative morbidity of laparoscopic surgery. However, utilisation is low, partly due to paucity of appropriately trained staff. This study aims to explore the barriers to the training of healthcare professionals in laparoscopic techniques in LMICs.
Method
Medline, Embase, Global Health and Web of Science databases were searched, using the key terms ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Eligible papers were in English, focused on abdominal laparoscopy and addressed barriers to training qualified health professionals. Papers focusing on advanced surgeries, paediatrics, and training in high-income countries were excluded. PRISMA guidelines for systematic reviews were followed.
Results
Funding was the first of seven key barriers identified, but feasible low-cost methods have been developed in some settings. Equipment limitations and lack of local trainers were highlighted, and expatriates may provide limited quality training opportunities. Stakeholder dynamics can create barriers, as can lack of knowledge on effective training curricula. Surgical departmental structure can limit the practical opportunities of trainees.
Conclusions
Themes are apparent across LMICs, but local factors reduce their generalisability, highlighting the need for larger-scale studies focusing on specific barriers. National investment in training programmes with research-backed curriculums and increased availability of local trainers and equipment is needed.
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Affiliation(s)
- E Wilkinson
- Nuffield Centre for International Health and Development, University of Leeds, United Kingdom
| | - N Aruparayil
- Leeds Institute of Medical Research at St. James’s, University of Leeds, United Kingdom
- NIHR Global Health Research Group in Surgical Technologies, Leeds, United Kingdom
| | | | - D Jayne
- Leeds Institute of Medical Research at St. James’s, University of Leeds, United Kingdom
- NIHR Global Health Research Group in Surgical Technologies, Leeds, United Kingdom
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6
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Abstract
Laparoscopic surgery has the potential to improve care in resource-deprived low-
and-middle-income countries (LMICs). This study aims to analyse the barriers to
training in laparoscopic surgery in LMICs. Medline, Embase, Global Health and
Web of Science were searched using ‘LMIC’, ‘Laparoscopy’ and ‘Training’. Two
researchers screened results with mutual agreement. Included papers were in
English, focused on abdominal laparoscopy and training in LMICs. PRISMA
guidelines were followed; 2992 records were screened, and 86 full-text articles
reviewed to give 26 key papers. Thematic grouping identified seven key barriers:
funding; availability and maintenance of
equipment; local access to experienced laparoscopic
trainers; stakeholder dynamics; lack of
knowledge on effective training curricula; surgical
departmental structure and practical opportunities
for trainees. In low-resource settings, technological advances may offer
low-cost solutions in the successful implementation of laparoscopic training and
improve access to surgical care.
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Affiliation(s)
- Ellen Wilkinson
- Nuffield Centre for International Health and Development, 4468University of Leeds, Leeds, UK
| | - Noel Aruparayil
- Leeds Institute of Medical Research at St. James's, 4468University of Leeds, Leeds, UK
| | - J Gnanaraj
- Rural Surgery Research and Training Center, Shanthi Bhavan Medical Center, Biru, India
| | - Julia Brown
- Leeds Institute of Clinical Trials Research, 4468University of Leeds, Leeds, UK
| | - David Jayne
- Leeds Institute of Medical Research at St. James's, 4468University of Leeds, Leeds, UK
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Gnanaraj J, Aruparayil N, Reemst P. Revisiting gasless laparoscopic surgeries for possible benefits during and after the COVID-19 pandemic. Trop Doct 2020; 51:123. [PMID: 32762303 DOI: 10.1177/0049475520945444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- J Gnanaraj
- MBBS MS (Gen), MCh (Urology) President Association of Rural Surgeons of India
| | | | - Peter Reemst
- MD President International Federation of Rural Surgeons
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8
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Bolton WS, Aruparayil N, Quyn A, Scott J, Wood A, Bundu I, Gnanaraj J, Brown JM, Jayne DG. Disseminating technology in global surgery. Br J Surg 2019; 106:e34-e43. [DOI: 10.1002/bjs.11036] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 10/02/2018] [Indexed: 12/12/2022]
Abstract
Abstract
Background
Effective dissemination of technology in global surgery is vital to realize universal health coverage by 2030. Challenges include a lack of human resource, infrastructure and finance. Understanding these challenges, and exploring opportunities and solutions to overcome them, are essential to improve global surgical care.
Methods
This review focuses on technologies and medical devices aimed at improving surgical care and training in low- and middle-income countries. The key considerations in the development of new technologies are described, along with strategies for evaluation and wider dissemination. Notable examples of where the dissemination of a new surgical technology has achieved impact are included.
Results
Employing the principles of frugal and responsible innovation, and aligning evaluation and development to high scientific standards help overcome some of the challenges in disseminating technology in global surgery. Exemplars of effective dissemination include low-cost laparoscopes, gasless laparoscopic techniques and innovative training programmes for laparoscopic surgery; low-cost and versatile external fixation devices for fractures; the LifeBox pulse oximeter project; and the use of immersive technologies in simulation, training and surgical care delivery.
Conclusion
Core strategies to facilitate technology dissemination in global surgery include leveraging international funding, interdisciplinary collaboration involving all key stakeholders, and frugal scientific design, development and evaluation.
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Affiliation(s)
- W S Bolton
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - N Aruparayil
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - A Quyn
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - J Scott
- Leeds Vascular Institute, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A Wood
- Department of Orthopaedic Surgery, Leeds General Infirmary, Leeds, UK
| | - I Bundu
- Department of Surgery, Connaught Hospital, Freetown, Sierra Leone
| | - J Gnanaraj
- Karunya Institute of Technology and Science, Karunya Nagar, Coimbatore, India
| | - J M Brown
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
| | - D G Jayne
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
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Daniel E, Anitha J, Gnanaraj J. Optimum laplacian wavelet mask based medical image using hybrid cuckoo search – grey wolf optimization algorithm. Knowl Based Syst 2017. [DOI: 10.1016/j.knosys.2017.05.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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10
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Gnanaraj J. Cystometrogram: the low-cost method for rural areas and its benefits. Trop Doct 2017. [PMID: 28637376 DOI: 10.1177/0049475517712658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cystometrography (CMG) is a means of studying bladder pressure. It is a very useful diagnostic tool in patients with lower urinary tract symptoms for which a simple cystoscopy will not offer sufficient information to form a diagnosis. Of the 8893 patients who underwent screening for urological conditions in rural northeast India during 2010-2014, 280 with lower urinary tract symptoms were investigated with a combination of cystoscopy and CMG. By corresponding CMG diagnosis and treatment, we could examine patients' overall satisfaction with both the procedure and the treatment. We describe a low-cost method of CMG and our results using this method in rural areas of India.
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Affiliation(s)
- J Gnanaraj
- Director Medical Services, Adjunct Professor, Karunya University, SEESHA Karunya Rural Community Hospital, Karunyanagar, Coimbatore, Tamil Nadu, India
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11
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Gnanaraj J. Low cost endo-loop for rural surgeons. Trop Doct 2017; 47:275-278. [PMID: 28058979 DOI: 10.1177/0049475516686540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Readymade endo-loops can make laparoscopic surgery convenient and faster. Commercially made endo-loops are expensive. We describe a method of making low-cost endo-loops from materials available in the operating room.
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Affiliation(s)
- J Gnanaraj
- Director of Medical Services, SEESHA, Karunya Rural Community Hospital, Coimbatore, Tamil Nadu, India
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12
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Gnanaraj J, Rhodes M. Laparoscopic surgery in middle- and low-income countries: gasless lift laparoscopic surgery. Surg Endosc 2015; 30:2151-4. [DOI: 10.1007/s00464-015-4433-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 07/10/2015] [Indexed: 01/08/2023]
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13
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Gnanaraj J. What happens next? Review of patients referred for further surgical treatment from rural/mission hospitals. CHRISMED J Health Res 2015. [DOI: 10.4103/2348-3334.158724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
Appendicectomy is the most common abdominal operation performed on an emergency basis in most parts of the world. The laparoscopic technique has many advantages over conventional open surgery especially in women and obese patients. A further improved version introduced recently is using a single-incision (SILS). Inducing a pneumoperitoneum, as a necessary precondition of laparoscopic procedures, represents a restriction of the surgeon’s freedom of movement and can lead to typical though rare complications. Gasless laparoscopic surgery has most of the advantages of laparoscopic surgery without many of the disadvantages. It is also less expensive, and can be combined with regional anaesthesia. Furthermore, fewer disposable materials are necessary. We describe a series of single umbilical incision gasless laparoscopic appendicectomies performed in rural areas of India.
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Affiliation(s)
- J Gnanaraj
- MS, MCh (urology), Director Medical Services, Seesha, Karunya Rural Community Hospital, Karunyanagar, Coimbatore, India
| | - Michael Rhodes
- MA, MBMCh, MD, FRCS, Chairman, Surgical Services Initiative, Attleborough, UK
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16
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Abstract
The method that we use has an initial cost (£150) and uses fewer materials for dressing daily than other methods. It is easy to use at the extremities and is effective in preventing amputation in some diabetics.
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Affiliation(s)
- J Gnanaraj
- SEESHA – Medical Services, Karunya Rural Community Hospital, Karunyanagar, Coimbatore, Tamil Nadu
| | | | - Arun Prasad
- Karunya University – EIE, Coimbatore, Tamil Nadu, India
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17
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Abstract
The Hegar's dilator could be used during both laparoscopic and open surgeries to find the correct planes to enter into either posterior or anterior fornix with minimal blood loss and with ease.
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Affiliation(s)
- J Gnanaraj
- SEESHA Karunya Rural Community Hospital, Karunyanagar Coimbatore, Tamil Nadu.
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Abstract
Poorly healing wounds are a bane to any surgical unit, but particularly in rural areas, and require a lot of effort to manage. One of the most effective recent methods that has been described is the application of topical negative pressure. We describe here a simple system made from the locally available materials that achieves this effect.
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Affiliation(s)
- J Gnanaraj
- Burrows Memorial Christian Hospital - Surgery, Alipur, Banskandi Post, Cachar District, Silchar, Assam 788101, India.
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Gnanaraj J, Ellapan B. Ureterorenoscopic removal of renal stones: cost-effective patient friendly method in rural areas. Trop Doct 2010; 41:102. [PMID: 20643869 DOI: 10.1258/td.2010.090318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Treatment of moderate-sized renal stones is difficult; we describe here a simple noninvasive method of removing them using the ureterorenoscope, the lithoclast and prior Double 'J' stenting. This method was successful in 101 out of 133 patients.
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Affiliation(s)
- J Gnanaraj
- Department of Surgery, Burrows Memorial Christian Hospital, Alipur, Banskandi Post Cachar District, Silchar, Assam 788101, India.
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Abstract
Minimally invasive surgeries are gaining popularity even in rural areas. Diagnostic laparoscopies overcome the disadvantages of open surgical procedures and provide useful diagnostic information. We describe a method of carrying out diagnostic laparoscopies using the cystoscope in rural areas.
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Affiliation(s)
- J Gnanaraj
- Burrows Memorial Christian Hospital, Alipur, Banskandi Post, Cachar District, Assam, India -788101.
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Lau SL, Debarm R, Thomas N, Asha HS, Vasan KS, Alex RG, Gnanaraj J. Healthcare planning in north-east India: a survey on diabetes awareness, risk factors and health attitudes in a rural community. J Assoc Physicians India 2009; 57:305-309. [PMID: 19702036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
AIMS AND OBJECTIVES To determine the level of awareness and knowledge about diabetes in the community, to identify their risk factors for diabetes, the relationship between anthropometric measures and diabetes risk and estimate the burden of diabetes in this rural North-East Indian population with an objective to identify target areas for future healthcare planning. MATERIALS AND METHODS A healthcare team conducted a community-based survey of the residents of Khowai district, Tripura. All household members above the age of 25 years were eligible to participate, following voluntary consent. Survey questionnaires were administered with interpreter assistance including demographic information, diabetes knowledge, family history, smoking, diet, healthcare access and the international physical activity questionnaire (IPAQ). Anthropometric measurements were taken and blood glucose testing performed. RESULTS One hundred and forty four participants completed the survey, 66 males and 78 females with a mean age of 44.4 +/- 14.8 years Although 91% had heard about diabetes and 44% were concerned about developing it in the future, only 39% were aware of its association with overweight status and 37% knew it required long-term treatment. Nine percent were known to have pre-existing diabetes mellitus and a further 9% were newly detected to have diabetes mellitus or impaired glucose tolerance. Fifteen percent were hypertensive and 8% had a family history of diabetes. Their mean BMI was 21.2 kg/m2 and 31% were overweight, despite high levels of physical activity in 47%. For each predictor of increased risk--waist circumference (female >80 cm, male >94 cm), waist-height ratio >50% or BMI>23 kg/m2, subjects measuring above the cut-off were more likely to have abnormal glucose tolerance than those in the normal range (27% vs. 14.3% p = 0.08, 26.5% vs. 9.5% p = 0.008, 27.3% vs. 13.3% p = 0.043, respectively.) with waist-height ratio being the best predictor of an abnormal BGL: OR 3.45 CI (1.34 - 8.88). CONCLUSION This is the first rural survey for diabetes in North-East India. This population had a low baseline knowledge and awareness about diabetes, despite significant diabetes prevalence. A greater emphasis on health education and risk factor modification for diabetes is warranted in the North-East part of the country.
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Affiliation(s)
- Sue L Lau
- Department of Diabetes & Endocrinology, Westmead Hospital, NSW Australia
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Gnanaraj J, Lionel J. Endometrial resection/vaporization: a patient-friendly first-option treatment for menorrhagia in rural areas. Trop Doct 2008; 38:103-4. [PMID: 18453503 DOI: 10.1258/td.2008.060115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hysterectomy, a major surgical procedure, is often an unacceptable procedure for many patients from rural areas who attend small rural hospitals. Near total endometrial resection/vaporization is a more acceptable procedure which can control menorrhagia. This procedure can be carried out with standard urology instruments.
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Affiliation(s)
- J Gnanaraj
- Burrows Memorial Christian Hospital, Alipur, India.
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Abstract
The value of minimally invasive appendicectomy is widely recognised. We report an alternative, and less invasive, method than the customary laparoscopic method.
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Affiliation(s)
- J Gnanaraj
- Burrows Memorial Christian Hospital, Alipur, Banskandi Post, Cachar District, Assam 788101, India
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Gnanaraj J, Jason LYX, Khiangte H. High quality surgical care at low cost: the diagnostic camp model of Burrows Memorial Christian Hospital (BMCH). Indian J Surg 2007; 69:243-7. [PMID: 23132995 DOI: 10.1007/s12262-007-0034-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2007] [Accepted: 12/15/2007] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The major problems that patients in rural areas face are related to accessibility, affordability and availability. AIMS OF THE STUDY This study aims to evaluate how effectively the Diagnostic Camp Model of the institution meets the surgical needs of rural patients, by examining the logistics, economics and extent of the service provided. SETTINGS AND DESIGN A retrospective study of patients attending the Diagnostic camps run by the staff of BMCH including the follow-up of these patients at the hospital. MATERIALS AND METHOD The diagnostic camps involve transporting medical personnel and modern diagnostic equipment into the interior villages of various North Eastern states of India. Patients requiring surgical intervention later attend the hospital for surgery with the assistance of a health insurance scheme. STATISTICAL ANALYSIS The local C3MDS computer software was used to obtain statistical reports from a diagnostic camp held at Saiha, Mizoram. Previous hospital data and the Government of India census were used to estimate the number of men requiring surgical intervention for Benign Prostatic Hyperplasia (BPH). RESULTS About three quarters of surgical patients, who attended the surgical camp were unaware of their diagnosis prior to the camp. There was an overall profit despite the expected losses at the Hospital. These camps are a feasible and profitable venture on their own. About 50% of patients estimated to require surgical intervention for BPH in three districts of Mizoram received the necessary interventions. CONCLUSION This model is an attractive, cost effective, efficient way of meeting the surgical needs of patients from a large geographical area.
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Affiliation(s)
- J Gnanaraj
- Alipur, Banskandi Post, Cachar District, Burrows Memorial Christian Hospital, Assam, 788 101 India
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Gnanaraj J, Devasia A, Gnanaraj L, Pandey AP. Intermittent self catheterization versus regular outpatient dilatation in urethral stricture: a comparison. Aust N Z J Surg 1999; 69:41-3. [PMID: 9932920 DOI: 10.1046/j.1440-1622.1999.01490.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The results of regular intermittent self catheterization were compared with regular outpatient dilatation after endoscopic internal urethrotomy for urethral strictures. METHODS The records of patients who were treated for urethral stricture disease over a 4-year period from 1991 to 1994 were reviewed. They were either on regular urethral dilatation or were advised to carry out self calibration. A follow-up questionnaire was sent to them and they were asked to attend a review. Student's t-test and Proportion Test were used to find out if there was any significant difference between the two groups. RESULTS There were 78 patients who were on self calibration and 49 patients on regular urethral dilatation. There was no significant difference between the two groups regarding the duration of follow-up (21.5 and 23.7 months, respectively); the length of stricture (1.5 and 1.7 cm, respectively); and complications (two and four, respectively). However, patients on self calibration had narrower strictures (4.8 and 5.7 F) and a significantly lower restricture rate (5 and 16%). The current urinary stream was compared to the immediate postoperative stream. This showed that a higher number of patients in the dilatation group were voiding at less than 25% of their immediate postoperative flow. People from high and low socio-economic groups were able to carry out self calibration satisfactorily. CONCLUSION Patients from high and low socio-economic groups found that self calibration resulted in a lower restricture rate and better stream when compared to regular urethral dilatation.
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Affiliation(s)
- J Gnanaraj
- Department of Urology, Christian Medical College and Hospital, Vellore, India.
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Gnanaraj J, Gnanaraj L, Shah VK. The triad that made the difference: duodenal ulcer--transverse incision, truncal vagotomy. Trop Doct 1998; 28:231-2. [PMID: 9803848 DOI: 10.1177/004947559802800416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- J Gnanaraj
- Department of Urology, Chinchpada Christian Hospital, Dhulia District Maharastra, India
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Affiliation(s)
- J Gnanaraj
- Department of Urology, Christian Medical College and Hospital, Vellore, India
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Abstract
In a mission hospital located in a tribal area in India we found that surgical patients were not coming to the hospital due to a variety of reasons. Table 1 summarizes the main problems and how they were overcome. The effectiveness of our efforts was reflected in the increase in the number of operations after these measures were carried out (1022 before and 1865 after).
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Affiliation(s)
- J Gnanaraj
- Department of Urology, Christian Medical College, Tamil Nadu, India
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Affiliation(s)
- J Gnanaraj
- Chinchpada Christian Hospital, Dhulia District, Maharastra, India
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Affiliation(s)
- J Gnanaraj
- Department of Urology, Christian Medical College & Hospital, Vellore, India
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Gnanaraj J, Gnanaraj L. The infant feeding tube: a boon to the rural urologist. Trop Doct 1996; 26:191. [PMID: 8937247 DOI: 10.1177/004947559602600425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- J Gnanaraj
- Department of Urology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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Gnanaraj J, Devasia A, Gnanaraj L, Gopalakrishnan G, Kekre NS. Bladder drainage during ureterorenoscopy: a new method. Br J Urol 1996; 78:299. [PMID: 8813933 DOI: 10.1046/j.1464-410x.1996.16129.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- J Gnanaraj
- Department of Urology, Christian Medical College & Hospital, Vellore, India
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