Cardiovascular Journal of Africa: Vol 27 No 3 (May/June 2016)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 3, May/June 2016 170 AFRICA
Tabula viva chirurgi: a living surgical document
Marius J Swart, Gina Joubert, Jan-Albert van den Berg, Gert J van Zyl
Abstract
Aim: The purpose of this article is to present the results of a
private cardiac surgical practice. This information could also
serve as a hermeneutical text for new wisdom.
Methods: A personal database of 1 750 consecutive patients
who had had coronary artery bypass graft (CABG) surgery
was statistically analysed. Mortality and major morbidity
figures were compared with large registries. Risk factors for
postoperative death were determined.
Results: Over a period of 12 years, 1 344 (76.8%) males
and 406 (23.2%) females were operated on. The observed
mortality rate was 3.03% and the expected mortality rate
(EuroSCORE) was 3.87%. After stepwise logistic regression,
independent risk factors for death were urgency (intra-aortic
balloon pump), renal impairment (chronic kidney disease,
stage III), re-operation and an additional procedure. Apart
from the 53 deaths, another 91 patients had major complica-
tions.
Conclusion: Mortality and morbidity rates compared favour-
ably with other international registries. Mortality was related
to co-morbidities. This outcome contributes to a hermeneu-
tical understanding focusing on new spiritual wisdom and
meaning for the surgeon.
Keywords: auto-ethnography, CABG, spirituality, surgery
Submitted 29/5/15, accepted 4/10/15
Cardiovasc J Afr 2016; 27: 170–176
DOI: 10.5830/CVJA-2015-081
Cardiac surgical risk models for postoperative mortality in
the South African context do not exist. An effort to set up a
registry or database for cardiac surgery was unsuccessful.1 Local
surgeons have to rely on results from outside South Africa to
compare their results. Risk models established in Europe or the
United States of America cannot necessarily be applied.2 Patient
profiles differ from region to region.
As an alternative, one can use the published results from
South African units as a yardstick. However, the reporting of
outcome after coronary artery bypass graft surgery (CABG)
is not common in South Africa. Between 1961 and 2009, five
articles informed on general outcome after CABG surgery.3 In
1972 Wentworth Hospital, Durban, described 20 patients who
had CABG surgery.4 In 1979 the Department of Cardiothoracic
Surgery at the University of the Free State published their results
on the first 50 CABG cases,5 and followed it up with the first 100
patients in 1983. 6 Groote Schuur Hospital contributed with 204
patients that were operated on between 1976 and 1978.7 In 1982,
Tygerberg Hospital added their 118 cases operated on between
1978 and 1980.8 None of these publications referred to mortality
risk.
After the literature search was repeated in 2014, a further
two reports on CABG outcome were found. Both were small in
number and both emphasised a specific subset of patients and
not CABG in general.9,10
One other author also contributed with published results after
CABG. A randomised, double-blind study from a single centre,
on the effect of aprotonin on cardiac surgery (50 CABG cases
and 50 valve cases), was conducted in the early 1990s at Groote
Schuur Hospital.11 This study had exclusion criteria and was not
representative of a cardiac surgical practice.
The first local comparison of outcome with a risk
score (EuroSCORE) appeared in the European Journal of
Cardiothoracic Surgery as a letter to the editor in 2004.12 Only
574 cases were involved, compared to the much larger numbers
of most European or American studies. The impact of impaired
renal function as calculated by the simplified modification of
diet in renal disease (sMDRD) and the metabolic syndrome on
CABG outcome was reported in two separate articles.13,14 These
studies excluded additional procedures in conjunction with
CABG and did not signify a true registry type of database.
Evaluating surgical outcome is common among cardiac
surgeons.15 Looking at mortality and morbidity rates is one way
of assessing outcome; however, a new interpretation of such data
could also lead to a different form of knowledge or wisdom. As
part of a spiritual reflection on negative outcomes after CABG
in an auto-ethnographic study, the database of one of the
authors (MJS) was presented as a personal document or text for
re-interpretation.16
The science of text interpretation is also known as
hermeneutics. Each human being can be read as a living
document, similar to a historical text or piece of art. According
to Gerkin, this reading of a living document could be an effort
to reconcile experience with theological language,17 hence the title
of this article: Tabula viva chirurgi: a living surgical document.
Theological language has a spiritual undertone. In the words of
Henri Nouwen, this spirituality should be a movement from the
restlessness of loneliness to the restfulness of solitude.18
The aim of this article was to acknowledge the negative
Bloemfontein Mediclinic; Health Sciences Education,
Faculty of Health Sciences, and Department of Practical
Theology, Faculty of Theology, University of the Free State,
Bloemfontein, South Africa
Marius J Swart, MB ChB, FCS (SA), PhD,
Department of Biostatistics, Faculty of Health Sciences,
University of the Free State, Bloemfontein, South Africa
Gina Joubert, BA, BSc, BSc (Hons), MSc
Department of Practical Theology, Faculty of Theology,
University of the Free State, Bloemfontein, South Africa
Jan-Albert van den Berg, BD, MDiv, MPhil, PhD
Dean, Faculty of Health Sciences, University of the Free
State, Bloemfontein, South Africa
Gert J van Zyl, MB ChB, MFam Med, MBA, PhD