The role of surgeon specialization in improving patient outcomes: a challenge for the Caribbean.

Progressive surgeon specialization has been shown to result in improved patient outcomes for many surgical procedures. This has been demonstrated in improved survival following cancer surgery and improved operative morbidity and mortality for other procedures. Concentrating complex surgical cases in centres where case volume and expertise exist should result in better overall surgical care delivery.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Clinicopathologic profile of gastric carcinomas at the University Hospital of the West Indies.

The objective of this study was to examine the clinicopathologic features of gastric cancer seen at the University Hospital of the West Indies (UHWI) and to compare the findings with other studies. A retrospective study was conducted using data obtained from the surgical pathology reports of all gastrectomies and gastric biopsies during the period January 1993 and December 2002. Additional cases were identified from the Department of Surgery's audit database. Demographic, clinical and pathological features were analyzed. Two hundred and sixteen patients were identified, 126 males and 90 females. One hundred and thirty-six underwent biopsy procedures but no definitive surgery aimed at cancer eradication, while 70 had gastrectomy. The peak age prevalence in both males and females was the 70-79-year age group. While the antrum was the commonest site, there was an overall increase in tumours of the gastro-oesophageal junction and tumours of the entire stomach in the latter five-year period of the review especially in the 50-59-year age group. Epigastric pain and constitutional symptoms were the common presenting features, and the most common gross tumour characteristic was an ulcerating mass, while histologically, the intestinal variety was most common. Lymph node metastases were common. Helicobacter pylori (Hpylori) were present in 16.7% while chronic multifocal atrophic gastritis was present in 40%. This study indicates that the gastric cancer pattern is typical of developing countries. However, the low prevalence of H pylori in the resected specimens may indicate the importance of other risk factors for gastric cancer development in this population. This warrants further study.

Benign breast diseases in an Afro-Caribbean population.

BACKGROUND: The diagnosis and effective treatment of benign breast disease still remains a clinical challenge and the need for surgical intervention has not been clearly defined. OBJECTIVES: To determine the patterns of benign breast disease in an Afro-Caribbean population in order to define the patterns of disease encountered and to review the approach to diagnosis and treatment. METHODS: A review of all breast biopsy operations performed for benign disease at the Kingston Public Hospital, Jamaica was made by examining a total of 333 patient records over a two year period. RESULTS: Of the cases reviewed this study clearly showed that the majority of benign breast lesions were due to fibrocystic disease (41%) and fibroadenomas (33%). Intraduct papillomatosis which accounted for 6.7% was the next in frequency. Other diseases found included fat necrosis 12 (4.4%) with breast abscess and mammary duct ectasia in eight patients (3%) each. Fourteen patients (5%) had no diagnostic abnormality. The mean age of patients with fibroadenoma was 20 years whereas the mean age of patients with fibrocystic disease was 40 years. The co-existence of fibrocystic disease with malignancy was reported in 15 cases. CONCLUSION: Benign breast disease in this population occurs mainly in young women less than 30 years of age. Eighty per cent of breast biopsies done in patients with palpable lumps are for benign disease. The data support a more conservative approach to diagnosis and management of these patients.

Analgesia-sedation for day-case inguinal hernia repair. A review of patient acceptance and morbidity.

The objective of this study was to determine whether analgesia-sedation improved patient acceptance of day-case herniorrhaphy and to evaluate the extent of patient morbidity. A total of 98 patients (mean age 34 years, range 17-75 years) were studied before and after herniorrhaphy to determine their response to the procedure. All patients were unpremedicated and underwent herniorrhaphy using a Bassini repair technique with a standard local anaesthetic block. Sedation was obtained with titrated intravenous midazolam(Hypnovel, Roche Products Ltd.) without narcotic analgesia. Patients were evaluated with a simple questionnaire after surgery. The maximum dose of midazolam used was 5 mg (median dose 3.5 mg). Monitoring of vital signs with pulse oximetry during the operative period was routine though oxygen therapy was not required. All patients were able to walk without assistance and were discharged under responsible supervision. Operative morbidity was low (5%). Adverse reactions to the procedure such as nausea, vomiting and headache were not seen. In conclusion, conscious sedation allows amnesia to be achieved with low morbidity in the majority of patients undergoing local anaesthetic procedures. This should result in increased patient acceptance.

Surgical management of perforated duodenal ulcer: the changing scene.

To determine the management of perforated duodenal ulcer at the University Hospital of the West Indies (UHWI) in this era of Helicobacter pylori, the medical records of all patients seen at the UHWI during the period July 1997 to June 2002 with an intra-operative diagnosis of perforated peptic ulcer were reviewed The records were analyzed for the following: age, gender, duration of symptoms, non-steroidal anti-inflammatory drug (NSAID) use, smoking status, operative repair duration of hospitalization, Helicobacter pylori status and medical therapy, peri-operative complications, mortality and recurrence. Ninety per cent of the cases were males. All females in whom perforation occurred were age 50 years and older compared to males where 58% of cases presented before age 50 years. Perforations in acute ulcers occurred in 80% of cases. The majority of patients were male smokers. Non-steroidal anti-inflammatory drug use was also an important risk factor in elderly females. Simple surgical closure and standard triple therapy antibiotics to eradicate Helicobacter pylori was the most common treatment offered. Mortality was one per cent and follow-up poor but 11% of patients had documented recurrent peptic ulceration. In this study population, perforated duodenal ulcer occured overwhelmingly in males less than 50 years of age. There is a trend towards exclusive simple surgical closure and H pylori eradication at the UHWI for patients with perforated duodenal ulcer but this needs to be supported by documentation of H pylori prevalence in the population of patients presenting with perforated peptic ulcers.

Pancreatitis and duodenal obstruction following abdominal aortic aneurysm repair.

This paper reports one case of pancreatitis and duodenal obstruction that occurred following repair of an abdominal aortic aneurysm. The patient had neither antecedent biliary or pancreatic disease nor alcohol abuse. The presentation was mild and the patient had an uneventful recovery without surgery. We present this uncommon entity and review the available literature.

Cancer of the colon and rectum in a Jamaican population: diagnostic implications of the changing frequency and subsite distribution.

The aim of this study was to examine the clinical and pathological characteristics of colorectal cancer in Jamaica, to determine whether there was a change in the anatomic distribution and clinical presentation and to discuss the options for diagnosis and management. A comprehensive retrospective review of patients newly diagnosed with colorectal carcinoma was conducted at The University Hospital of the West Indies by reviewing both patient records and pathological data. These data were compared with previous reports of patients with colorectal cancer seen in Jamaica. One hundred and forty-seven patients were studied There were 85 females and 62 males with a female to male ratio of 1.37:1. The median age was 65.5 years (range 19 to 94 years). The predominant symptoms were abdominal pain in 91 patients, change in bowel habit in 77 patients and rectal bleeding in 74 patients. Sixty patients presented with weight loss and 28 with a rectal mass. The most common tumours were right-sided colonic cancers in 42 patients (28.5%) followed by sigmoid colon in 30 (20.4%) rectum in 34 (23.1%) and left and transverse colon accounting for 16 and 10 cases respectively. Most of the tumours were well or moderately differentiated adenocarcinomas. Only eight patients presented with Dukes' A disease, 50 with Dukes'B, 53 with Dukes'C disease and 34 with advanced disease. The findings showed that sigmoid and rectal tumours accounted for 43.5% of cancers. The colon/rectum ratio in this series was 3.3:1 indicating a significant proximal shift of colorectal cancers in this population in keeping with recent reports. The results of the current study suggest that the sub-site location of colorectal cancers seen is similar to that reported in high incidence countries such as the United States of America and parts of Europe but differs from the African continent which has a high proportion of rectal tumours. This right-sided preponderance also differs from previous studies in Jamaica, which report a higher incidence of rectal lesions The detection of early colorectal carcinoma will require screening at a stage when the disease is asymptomatic in order to improve the chance for cure. The data presented here imply that screening programmes should allow evaluation of the entire colon rather than the distal 25 cm.

Civilian rectal trauma: the surgical challenge.

Using the Department of Surgery, Radiology, Anaesthesia and Intensive Care's operative database and information from the Trauma Registry for patients presenting after 1998, a retrospective study of patients seen between the period 1992 and 2002 was done at the University Hospital of the West Indies with the objective of determining the treatment and outcome of patients with a diagnosis of rectal trauma. Over the 10-year period, 45 patients were seen with this diagnosis. Eighty-two per cent of the cases were males, with a mean age of 29.8 years (range 16-70 years) while the eight female patients had a mean age of 36.8 years. Low velocity gunshot wounds accounted for 64% of the entire group and for 78% in males. Six of the eight cases seen in females were iatrogenic occurring during gynaecological operations. Sixty-three per cent of rectal injuries were associated with other injuries with the genitourinary system most commonly involved The majority (83%) were diagnosed preoperatively by visualization of the rectal wound or the presence of blood on proctosigmoidoscopy. All the patients had peri-operative antibiotics and diversion with a proximal sigmoid colostomy. Fifteen per cent of cases had presacral drain insertion. Distal rectal washout was not used. There were no deaths. Seventy-three per cent of patients had closure during the period under review at an average time of 8.5 months after initial surgery. The other 27% after an average of 23 months did not have documented closure. The mainstay of treatment for civilian rectal trauma remains diverting sigmoid loop colostomy, despite its morbidity, and peri-operative antibiotics.

Management of hepatic cysts by percutaneous drainage and instillation of tetracycline hydrochloride.

This paper reports two cases of benign hepatic cysts successfully treated by the instillation of tetracycline hydrochloride. The patients presented with solitary large symptomatic hepatic cysts and underwent ultrasound guided needle aspiration followed by the instillation of tetracycline hydrochloride. The cyst size diminished without complication and the patients have remained symptom free. We review the treatment of this uncommon entity and propose that injection of tetracycline hydrochloride is an effective nonoperative treatment of symptomatic solitary hepatic cysts.

Endoscopic retrograde cholangiopancreatography use at the University Hospital of the West Indies.

All patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at the University Hospital of the West Indies (UHWI) were entered into a prospective database. Parameters included demographics, indication for the procedure, success of the ERCP and any immediate complications noted. Retrospectively, the patients' case notes were analyzed for complications developing after 24 hours, and outcome. During the period March 1999 to December 2002, a total of 120 consecutive patients were subjected to 123 ERCPs, all being performed by a single gastroenterologist. Of these 120 patients, eight had ERCP as outpatients and were transferred back to their referring hospitals. These patients were excluded from further analysis. Of the 115 UHWI patients, the case notes of 96 were available for analysis and this group formed the basis of this review. ERCP had successful cannulation in 95% of patients. There were 70 females and 26 males with a female to male ratio of 2.7:1. Age ranged from 13 to 85 years (mean +/- SD, 43 +/- 17), males being an average six years older than females. The most common indication for ERCP was a patient with cholelithiasis and abnormal liver function tests scheduled for laparoscopic cholecystectomy. This made up 33% of patients and in this subgroup, sickle cell disease accounted for 50% of cases. Patients with common bile duct stones preoperatively and post-cholecystectomy accounted for 13% and 17% respectively while gallstones pancreatitis accounted for 13% of cases, including three patients with severe pancreatitis. While 64% of the patients had normal cholangiogram, 66% of them had sphincterotomy. Common bile duct stones were seen in 23 cases and complete removal was successful in 48%. There were ten cases (10%) of ERCP pancreatitis and this was severe in three patients and the direct cause of death in one. One patient had ascending cholangitis post ERCP and there were no cases of post-sphincterotomy bleeding or duodenal perforation. Endoscopic retrograde cholangiopancreatography at the UHWI has high diagnostic yield but its therapeutic use needs further development.

Mucinous cystadenoma of the appendix presenting with an elevated carcinoembryonic antigen (CEA): Report of two cases and review of the literature.

INTRODUCTION: Despite the fact the mucocoele of the appendix is a rare entity it has been the subject of much interest in the literature. The term mucocoele refers to cystic dilatation of the appendix filled with mucin resulting from proximal obstruction of the appendix lumen. PRESENTATION OF CASE: We report two patients presenting with mucinous cystadenoma of the appendix with elevation of serum carcinoembryonic antigen (CEA), which has rarely been reported. Both patients had mild symptoms and a normal colonoscopy preoperatively. The diagnosis was not suspected in one patient prior to surgery. The elevated CEA prompted additional diagnostic radiologic investigations including ultrasonography, and computed tomography scans. The patients had uneventful appendicectomies with subsequent normalization of their CEA levels. DISCUSSION: Mucinous cystadenoma of the appendix is a rare pathological entity characterized by a dilated mucous filled appendix. The presence of an elevated CEA associated with the presence of this entity is a rare presentation. CONCLUSION: Because the diagnosis is rarely suspected prior to surgery patients with an enlarged appendix with associated elevated CEA levels should have careful investigations to exclude malignancy.

Dengue fever mimicking acute appendicitis: A case report.

INTRODUCTION: Dengue fever is an acute viral disease, which usually presents as a mild febrile illness. Patients with severe disease present with dengue haemorrhagic fever or dengue toxic shock syndrome. Rarely, it presents with abdominal symptoms mimicking acute appendicitis. We present a case of a male patient presenting with right iliac fossa pain and suspected acute appendicitis that was later diagnosed with dengue fever following a negative appendicectomy. PRESENTATION OF CASE: A 13-year old male patient presented with fever, localized right-sided abdominal pain and vomiting. Abdominal ultrasound was not helpful and appendicectomy was performed due to worsening abdominal signs and an elevated temperature. A normal appendix with enlarged mesenteric nodes was found at surgery. Complete blood count showed thrombocytopenia with leucopenia. Dengue fever was now suspected and confirmed by IgM enzyme-linked immunosorbent assay against dengue virus. DISCUSSION: This unusual presentation of dengue fever mimicking acute appendicitis should be suspected during viral outbreaks and in patients with atypical symptoms and cytopenias on blood evaluation in order to prevent unnecessary surgery. CONCLUSION: This case highlights the occurrence of abdominal symptoms and complications that may accompany dengue fever. Early recognition of dengue fever mimicking acute appendicitis will avoid non-therapeutic operation and the diagnosis may be aided by blood investigations indicating a leucopenia, which is uncommon in patients with suppurative acute appendicitis.

Actinomycosis of the colon with invasion of the abdominal wall: An uncommon presentation of a colonic tumour.

Actinomycosis is an uncommon chronic suppurative infectious disease that is caused by Actinomycetes organisms, which are gram-positive, microaerophilic, anaerobic bacteria. The most common type causing disease in humans is Actinomyces israelii. This organism is a commensal of the human mouth and is seldom pathogenic. When it does cause disease, however, three main clinical types of involvement are recognized including cervico-facial, thoracic and abdominal actinomycosis.Herein, we present the case of a 79-year-old male patient who underwent surgical exploration following presentation with abdominal pain and an abdominal mass, initially thought to be a malignancy. Pathologic examination confirmed this as a case of abdominal actinomycosis. This diagnosis should always be included in the differential diagnosis of patients who present with an infiltrative abdominal mass.

Emergency department thoracotomy in Jamaica: a case controlled study.

Increasing numbers of severely injured patients have been presenting to Emergency Rooms worldwide due to advances in pre-hospital trauma care. Some of these patients may be candidates for Emergency Department Thoracotomy (EDT). Large advisory bodies have identified selection criteria for EDT in Developed Countries, but there are no regional statistics to guide the selection process in Developing Caribbean Nations. This study evaluates outcomes with EDT at the University Hospital of the West Indies in Jamaica in order to determine factors that could predict survival in this setting. A retrospective study was performed over 11 years from January 1995 to January 2006 examining patients who had EDT at the University Hospital of the West Indies. There were 13 procedures performed over 11 years, with two early survivors (15%) and one patient surviving to discharge. The factors that have been found to be significant predictors of mortality include gunshot injuries, extra-thoracic injury location, inadequate pre-hospital resuscitation, prolonged transportation time and the absence of signs of life on arrival to hospital. Several health care limitations have been uncovered in this setting that must be improved if we are to expect improved outcomes. Focused preparation of the Emergency Room is an initial step that can be easily achieved. We also need to define strict management protocols using selection criteria that are tailored to our local environment in order to exclude futile procedures in unsalvageable patients.

Selective operative cholangiography in the performance of laparoscopic cholecystectomy.

The objective of this prospective study was to evaluate the role of intraoperative cholangiography (IOC) for patients undergoing laparoscopic cholecystectomy (LC) to determine whether it could be safely omitted for all patients who fit standard criteria, namely normal liver function tests, no history of gallstone pancreatitis, common bile duct (CBD) diameter less than 10 mm or previous history of jaundice. Data were collected prospectively from 194 consecutive patients who had LC for symptomatic gall bladder disease. IOC was not performed in any patient. The conversion rate was 6.1% and one CBD injury occurred. Our experience demonstrates that LC performed without routine IOC does not result in an increased incidence of retained stones in selected patients who have no history of pancreatitis, normal liver function tests and CBD less than 10 mm diameter.

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

A consecutive series of 14 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.