Management of symptomatic gallstone disease: Equity between two healthcare delivery systems in Trinidad & Tobago

Objective: Patients with symptomatic gallstones require laparoscopic cholecystectomy (LC) to remove the gallbladder to avoid complications. LC should be performed with as little delay as possible. We sought to determine whether the health care delivery systems in Trinidad & Tobago were adhering to best practices. Design and Methodology: At a public and a private institution, the general surgical operating theatre registers were reviewed for the period Jan 2016 to Aug 2018 to identify all patients having undergone LC. Hospital records were then retrieved and retrospectively reviewed. The following data were extracted: patient demographics, index diagnosis, date of index diagnosis, interval between index diagnosis and LC, complications between index diagnosis and LC, duration of LC, complications after LC. Results: 98 patients were studied from both centers with a mean age of 44.8 years ± 12.4(SD) and 92.8% were female. The most common indication for cholecystectomy overall was biliary colic (31.6%). For patients with biliary colic, the mean waiting time for LC was 289.3 days ± 521.5 (SD) days at the public institution compared to 9 days ± 6 (SD). Acute cholecystitis accounted for 30% of diagnoses at both centers. The mean waiting times for patients who presented with acute cholecystitis was 392.9 ± 876.2 days (mean ± SD) in the public healthcare system vs 26.1 ±27.3 days (mean ± SD) in the private healthcare system. Conclusions: There is some disparity in management of symptomatic gallstones between the private and public healthcare systems in Trinidad & Tobago. Specifically, a statistically significant difference in waiting times to complete LC exists between the systems.

Common bile duct stones in sickle-cell disease - abstract

Common bile duct (CBD) stones were found intra-operatively in 12 patients (11 SS, 1 SC) among 36 patients with homozygous sickle-cell (ss) disease and 2 patients with sickle-cell haemoglobin C (SC) disease subjected to cholecystectomy between January, 1985 and December, 1992. Pre-operatively, ultrasonography had identified common bile duct stones in only 5 of these 12 patients. Operative cholangiography was diagnostic in 11 and equivocal in one. Following exploration of the common bile duct, immediate closure was performed in one, transduodenal sphincteroplasty in one, insertion of a T-tube in 4, and choledochoduodenostomy (CDD) in 6. Retained CBD stones were detected in 2 patients on routine T-tube cholangiography performed on the 10th postoperative day, and in both were successfully dislodged by saline irrigation. The high frequency of CBD stones in this symptomatic group of patients receiving cholecystectomy justifies routine diagnostic operative cholangiography. Saline irrigation intra-operatively may successfully remove stones, reducing the risk of iatrogenic damage by ductal instrumentation. Marked ductal dilatation with calculi can be treated successfully by CDD (AU)