Massive ascites secondary to severe endometriosis

Massive ascites is an unusual association with endometriosis. This case report is of such a condition in an Afro-Jamaican woman. The diagnosis was made at laparotomy and conservative treatment was adopted allowing for retention of reproductive function. Postoperative therapy was Goserelin, a Gonadotropin Releasing Hormone (GnRH) agonist, for six months. This relieved all of her symptoms. However, long term follow-up is needed, as recurrence is possible.(AU)

Pain control after major surgery

OBJECTIVE: To assess the adequacy and efficacy of postoperative pain management. DESIGN: A prospective clinical study. SETTING: The Georgetown and New Amsterdam Public Hospitals, Guyana. SUBJECTS: Two hundred consecutive patients undergoing major abdominal surgery. MAIN OUTCOME MEASURES: Presence or absence of significant postoperative pain during the first 24 hours. RESULTS: All the patients experienced pain postoperatively. Sixty one percent of patients considered their pain severe, 30 percent rated it moderate and only 9 percent mild. Reasons for this deficiency of care are partly attributable to the patients themselves and also the health care staff. CONCLUSIONS: Postopertive pain is poorly managed in our general hospitals. (AU)

Necrotising enterocolitis: A management protocol for developing countries

28 cases of necrotising enterocolitis (NEC) comprising 11 term and 17 preterm patients were diagnosed between January 1990 and December 1995 at the University Hospital of the West Indies (UHWI). Treatment was in accordance with a management protocol which emphasised aggressive screening of potential cases, early laparotomy for bowel perforation and primary anastomosis after small bowel resection. There were three deaths among the 13 cases of bowel perforation. Centres in developing countries can achieve rates of survival comparable to those in the developed world in babies with NEC weighing over 1000 grams by adopting the UHWI management protocol.(AU)

Non-operative management of stab wounds to the abdomen with omental evisceration

A consecutive series of 12 patients with anterior abdominal stab wounds and omental evisceration treated at the Kingston Public Hospital Jamaica over a 3-year period is presented. During this period 223 patients with abdominal stab wounds were seen of which 66 had omental evisceration. Conservative surgical management was the approach followed in 14 patients who presented without signs of peritonitis. There were no late complications or missed visceral injuries necessitating laparotomy. Serial physical examination was the method used to select patients for conservative surgical management with the exclusion of patients with deteriorating clinical signs or peritonitis. Omental evisceration through an abdominal stab wound in a patient with stable clinical signs and without evidence of peritonitis is not an absolute indication for exploratory laparotomy. (AU)

Management of penetrating abdominal injuries

One hundred and twelve patients with penetrating abdominal injuries seen at the Kingston Public Hospital, Jamaica, over a twelve month period from January 1 to December 31, 1992 were reviewed. Seventy-five (67 percent) patients had stab wounds and thirty-seven (33 percent) sustained gunshot wounds. There were 10 deaths (27 percent) from gunshot wounds, and seven deaths (9 percent due to stab wounds. Using a protocol of selective conservatism for stab wounds, 41 (60 percent) were observed, 27 (40 percent) explored and 5 (12 percent) patients had negative laparotomy. The male to female ratio was 10: with 88 percent in the age group 16-35 years. A decision to perform laparotomy was used and is recommended (AU)

The rapunzel syndrome: report of a case and review of the literature

The Rapunzel Syndrome, a rare manifestation of trichobezoar, occurs when bolus gastrointestinal obstruction is produced by an unusual trichobezoar with a long tail that extends to or beyond the ileocaecal valve. A five-year-old Jamaican girl presented with this abnormality and was found at laparotomy also to have an ileo-ileal intussuception. For the Rapunzel Syndrome, we recommended bezoar extraction at laparotomy via multiple enterotomies. In addition, psychiatric evaluation and therapy is essential due to the commonly associated finding of underlying emotional stress. (AU)

Evaluation of transabdominal ultrasonography for ectopic pregnancy

Ultrasound examination was performed on 66 patients with suspected ectopic pregnancy. Of 23 women who had the diagnosis confirmed at laparotomy, 16 (69.6 percent) were correctly identified on ultrasound, 4 were reported as unliklely ectopic pregnancies and 3 were undetermined. Two patients with false negative ultrasound reports had positive findings on the ultrasound, but the findings were misinterpreted. Correct identification of these would have increased the true positive rate to 78.3 percent and decreased the false negative rate to 8.8 percent. There were 5 false positive reports due to overian cysts (AU)

Abdominal pregnancy

Two cases of abdominal pregnancy are reported: one from the Castle Street Hospital for Women, Colombo, Sri-Lanka and the other from the Queen Elizabeth Hospital, Barbados, West Indies. The clinical manifestations, diagnosis and management are described. A review of the literature is presented. (AU)

Experience with abdominal field block for laparotomy in critically III patients: a preliminary report - abstract

Patients undergoing laparotomy are usually anaesthetized using conventional general endotracheal anaesthesia with controlled respiration and/or spinal or epidural block. When critically ill patients (ASAIV - V, Gold-mann's score > 26) present for abdominal surgery of short duration, these methods cannot be considered ideal; the associated cardio-respiratory instability and impaired neuromuscular function sometimes necesitate prolonged intubation and controlled respiration in the Intensive Care Unit (ICU). The complications of these were well-known. From June 1987 to November 1988, 25 patients of the above physical status (age range from 3 days to 81 years) had undergone abdominal surgery of short duration (30 to 110 minutes) under general anaesthesia and required ICU admission. Their stay in ICU was from 1 to 36 days. Thirteen died in the first admission, 3 required re-admission and died. At the end of the study, 9 patients were alive. There was clinical, radiological and autopsy evidence of pulmonary infection and ARDS in all these cases. Concurrently 12 patients, of similar physical status and age range ( 2 days to 82 years), were subjected to short abdominal procedures and Caesarean Sections (45 to 111 minutes) under abdominal-field-block. It was supplemented when necessary with "light" (patient arousable to command). All patients were returned to the ward after a short stay in the recovery room. There were 3 deaths, one on the 5th day and 2 on the 8th day; autopsy showed that these were due to the primary pathology. Abdominal-field-block seems a satisfactory technique in poor-risk patients for abdominal procedures of short duration. The avoidance of prolonged intubation, controlled respiration and their complications offer distinct advantages; it is also cost-effective (AU)

The Natural history of vertical abdominal parietal closure: a prospective study of Prolene (PPL) versus Dexon (PGA) - [abstract]

Synthetic absorbable sutures are commonly used for abdominal wall closure following laparotomy, but the long-term outcome of such wound closure is uncertain. To determine the natural history, 200 consecutive patients were randomized to closure of vertical laparotomy wounds with continuous simple sutures of No 1 PPL (nonabsorbable) -95 wounds, or Smead sutures of No 1 PGA (absorbable) -105 wounds. Two patients from each group were withdrawn because of death or reoperation within the first week. The remainder were followed postoperatively for wound complications and were examined at 1, 3, 6, and 12 months, and at 2 and 5 years for incisional hernias. Wounds were midline in 194 patients and were lower abdominal in 52. The treatment groups were evenly matched. The mean rate of fascial closure was 41 sec/cm with PPL wounds and 49 sec/cm with PGA. Wound infections (WI) occured in 20 PPL and 12 PGA wounds, and ileus and respiratory complications were equal in the groups. The single wound dehiscence (0.52 percent) was due to slippage of a PPL knot. Analysis by the life table method showed a 12 percent wound failure rate at 5 years for PPL compared with 21 percent for PGA. Among 93 wounds closed with PPL, 2 hernias developed within the first year, and 2 over the next four years. But of 103 wounds closed with PGA, 1 developed a hernia in the first year, and 10 did so in the next 4 years (P = 0.01). In each group only 2 hernias occured in patients who had had wound infections. The findings show that PPL and PGA both allow rapid and secure closure of midline laparotomy incisions; but PGA is associated with an unacceptable rate of late herniation (AU)

Torsion of a gastric leiomyoma

A patient with an extraluminal gastric leiomyoma, which presented as an emergency because of torsion, is reported. This is thought to be the first report of such an occurrence. The diagnosis was not made preoperatively in spite of intensive investigation.(AU)

Ruptured tubal ectopic pregnancy in Guyana - abstract

This is a study of 243 cases of ruptured tubal ectopic pregnancies in Guyana during the 4 years from 1959 to 1962. Since this condition is much commoner in tropical countries, specific diagnostic features and the management considered appropriate in the circumstances are outlined. Incidence was very high especially in 2 groups: (a) Patients with a long period of infertility prior to precipitation of ectopic pregnancy. (b) Those who had any previous operative procedure on the fallopian tube, such as, salpingostomy, salpingolysis, or salpingoplasty. The special diagnostic features observed were: (a) Rapidly developing or progressive anaemia (b) Scanty vaginal bloody discharge or none at all (c) Conspicuous tenderness in the right or left iliac fossa (d) Tumid and tender abdomen (e) History of amenorrhoea. The principle of quick diagnosis and prompt laparotomy has been followed. The affected tube was excised, the ovary conserved, and the tube and ovary of the other side inspected. Intra-peritoneal blood was aseptically collected, strained, citrated and trasfused. Auto transfusion has the advantage of providing compatible blood immediately. There were no deaths in this series and the post operative period was uneventful. Antibiotics were used in the post operative period (AU)

The acute abdomen during pregnancy: report of three unusual cases

The details of three cases are presented in which surgical emergencies arose during the course of pregnancy. These consisted of torsion of the spleen, traumatic rupture of the spleen and a volvulus with internal hernia involving large and small bowel. Details of management are discussed as well as the implications of such conditions during pregnancy. (AU)

Spontaneous organic hypoglycaemia

Three cases encountered in the past five years in Trinidad were presented. All were females, aged 15, 30 and 66 years. Two cases presented with convulsions. All three patients underwent laparotomy and in only one was any pathological change noted: an anaplastic carcinoma of the pancreas with nodal metastases (AU)