Comment on 'Achenbach syndrome in an older man'.

We comment on a previous letter regarding Achenbach syndrome, and suggest that punch biopsy should be performed in all clinically suspected cases to obtain histological confirmation of the disease.

Human liver umbilical fissure variants: pons hepatis (ligamentum teres tunnel).

PURPOSE: In the classical description of normal liver anatomy, the umbilical fissure is a long, narrow groove that receives the ligamentum teres hepatis. The pons hepatis is an anatomic variant, where the umbilical fissure is converted into a tunnel by an overlying bridge of liver parenchyma. We carried out a study to evaluate the existing variations of the umbilical fissure in a Caribbean population. METHODS: We observed all consecutive autopsies performed at a facility in Jamaica and selected cadavers with a pons hepatis for detailed study. A pons hepatis was considered present when the umbilical fissure was covered by hepatic parenchyma. We recognized two variants: an open-type (incomplete) pons hepatis in which the umbilical fissure was incompletely covered by parenchyma ≤ 2 cm in length and a closed type (complete) pons hepatis in which the umbilical fissure was covered by a parenchymal bridge > 2 cm and thus converted into a tunnel. We measured the length (distance from transverse fissure to anterior margin of the parenchymatous bridge), width (extension across the umbilical fissure in a coronal plane) and thickness (distance from the visceral surface to the hepatic surface measured at the mid-point of the parenchymal bridge in a sagittal plane) of each pons hepatis. A systematic literature review was also performed to retrieve data from relevant studies. The raw data from these retrieved studies was used to calculate the global point prevalence of pons hepatis and compared the prevalence in our population. RESULTS: Of 66 autopsies observed, a pons hepatis was present in 27 (40.9%) cadavers. There were 15 complete variants, with a mean length of 34.66 mm, mean width of 16.98 mm and mean thickness of 10.98 mm. There were 12 incomplete variants, with a mean length of 17.02 mm, width of 17.03 mm and thickness of 9.56 mm. The global point prevalence of the pons hepatis (190/5515) was calculated to be or 3.45% of the global population. CONCLUSIONS: We have proposed a classification of the pons hepatis that is reproducible and clinically relevant. This allowed us to identify a high prevalence of pons hepatis (41%) in this Afro-Caribbean population that is significantly greater than the global prevalence (3.45%; P < 0.0001).

Hepatic surface grooves in Trinidad and Tobago.

PURPOSE: Hepatic surface grooves (HSGs) are prominent depressions on the antero-superior surface of the liver. We sought to document the prevalence of HSGs in an Eastern Caribbean population. METHODS: We observed all consecutive autopsies performed at a facility in Trinidad and Tobago and recorded the presence, number, location, width, length and depth of any HSG identified. Each liver was then sectioned to document intra-parenchymal abnormalities. RESULTS: Sixty Autopsies were observed. There were HSGs in 9 (15%) cadavers (5 females and 4 males), at an average age of 66 years (range 48-83, Median 64, SD ± 10.4). The HSGs were located on the diaphragmatic surface of the right hemi-liver in 8 (89%) cadavers, left medial section in 4 (44%), left lateral section in 3 (33%) and coursing along Cantlie's plane in 3 (33%) cadavers. Eight (89%) cadavers with HSGs had other associated anomalies: accessory inferior grooves (5), parenchymal nutmeg changes (5), abnormal caudate morphology (4), hyperplastic left hemi-liver (3), lingular process (2), bi-lobar gallbladder (1) and/or abnormal ligamentous attachments (1). CONCLUSIONS: Approximately 15% of unselected Afro-Caribbean persons in this Eastern Caribbean population have HSGs. Every attempt should be made to identify HSGs on pre-operative imaging because they can alert the hepatobiliary surgeon to: (1) associated anatomic anomalies in 89% of cases, (2) associated hepatic congestion in 56% of persons, (3) increased risk of bleeding during liver resections and (4) increased technical complexity of liver resections. The association between HSGs, cardiovascular complications, hepatic congestion and nutmeg liver prompted us to propose a new aetiologic mechanism for HSG formation, involving localized hyperplasia at growth zones due to upregulation of beta-catenin levels.

Declaration of a state of emergency in Trinidad and Tobago: effect on the trauma admissions at the National Referral Trauma Centre.

OBJECTIVE: To determine the effect of a State of Emergency (SOE) on penetrating injuries at the main trauma center in Trinidad and Tobago. METHODS: Emergency room registers were accessed in order to identify all patients treated for penetrating injuries from July 1, 2010 through December 30, 2012. This study period was chosen to include injuries one year before and one year after the SOE that spanned from August 21, 2011 to December 5, 2011. Data were analyzed using SPSS version 19 and a P value<.05 was considered statistically significant. RESULTS: There were 1,067 patients treated for penetrating injuries. There were significantly more injuries from gunshots compared to stab wounds (64.7% vs 35.3%; P<.001), and this pattern was maintained during the SOE (54.7% vs 45.3%; P=.37). There was a significant fall in mean monthly admissions for penetrating trauma during the SOE when compared to the 12-month period before its imposition (17.7, SD=4.0 vs 38.9, SD=12.3; CI, 5.6-36.8; P=.0108). One year later, mean monthly admissions for penetrating trauma were similar to those during the SOE (22.7, SD=2.1 vs 17.6, SD=4.0; CI, -2.3-12.3; P=.1295). The incidence of gunshot wounds remained low and stab wounds increased. CONCLUSION: This study has demonstrated that there was a reduction in the incidence of penetrating trauma at the national trauma center after the SOE, with a shift from gunshot to stab wounds.

Laparoscopic Repair of Sportman's Hernia - The Trinidad Experience.

Sportman's hernia: (Athletic pubalgia) is an uncommon and poorly understood condition afflicting athletic individuals. Sufferers complain of chronic groin pain and often present diagnostic dilemmas to physicians and physiotherapists. We present a series of cases illustrating the varying presentations of sportman's hernia and diagnostic approaches that can be utilized to exclude common differentials. We also describe laparoscopic mesh repair as an effective treatment option for this condition.

The Original Rutherford Morison Incision: A Case Report.

In recent years, the Rutherford Morison incision has become synonymous with renal transplant surgery. However, this incision was originally intended for access to the sigmoid colon and pelvis, particularly in the case of a midline previously scarred from operation. We present a case of a middle-aged female with a caecal tumour, requiring resection. Upon examination, this patient was found to have large concomitant diastasis of the recti. A right-sided Rutherford Morison incision was utilized in performing a right hemicolectomy. Although the advantages of a minimally invasive approach to colonic resections are well described, laparoscopy was not utilized in the case discussed. Due to the wide area of anterior abdominal wall laxity, herniation is likely to develop at both port placement and specimen delivery sites. A similar outcome would result from a midline incision. However, a paramedian is an acceptable alternative to a Rutherford Morison incision in a case like this, as it is known to have very low rates of post-operative incisional herniation. While in modern times, its use may have become repurposed, the Rutherford Morison incision is one which should be remembered and used in the surgeons' armamentarium to improve clinical outcomes when necessary.

Isolated Perforation of Multiple Jejunal Diverticulae: A Very Rare Cause of Acute Abdomen.

Isolated jejunal diverticular (JD) perforation is extremely rare; it usually presents as a diagnostic dilemma and is often discovered incidentally on laparotomy. Most of these perforations are single. Literature has revealed only one case of multiple small bowel diverticular perforations. We report the first case of simultaneous perforation of four jejunal diverticulae in an 85-year-old male. Small bowel resection and primary anastomosis were performed. The patient had an uneventful post-operative recovery. This case highlights the importance of prompt diagnosis and timely management to reduce the morbidity and mortality of these patients. It should be included in the differential diagnosis in all elderly patients presenting with acute abdomen.

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy.

BACKGROUND: Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer, but we have experienced resistance to the introduction of the FreeHand® robotic camera holder to augment laparoscopic colorectal surgery. AIM: To compare the initial results between conventional and FreeHand® robot-assisted laparoscopic colectomy in Trinidad and Tobago. METHODS: This was a prospective study of outcomes from all laparoscopic colectomies performed for colorectal carcinoma from November 29, 2021 to May 30, 2022. The following data were recorded: Operating time, conversions, estimated blood loss, hospitalization, morbidity, surgical resection margins and number of nodes harvested. All data were entered into an excel database and the data were analyzed using SPSS ver 20.0. RESULTS: There were 23 patients undergoing colectomies for malignant disease: 8 (35%) FreeHand®-assisted and 15 (65%) conventional laparoscopic colectomies. There were no conversions. Operating time was significantly lower in patients undergoing robot-assisted laparoscopic colectomy (95.13 ± 9.22 vs 105.67 ± 11.48 min; P = 0.045). Otherwise, there was no difference in estimated blood loss, nodal harvest, hospitalization, morbidity or mortality. CONCLUSION: The FreeHand® robot for colectomies is safe, provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Primary Retroperitoneal Serous Cyst Adenoma: A Case Report and Literature Review.

Primary retroperitoneal serous cyst adenomas (PRSCs) are extremely rare thin-walled cystic lesions whose pathogenesis is not well understood. Clinical presentation varies depending on the lesion's size and location, i.e., larger lesions compress adjacent organs, giving the impression of malignancy. Although advances in imaging techniques enable to identify various characteristics of retroperitoneal cystic lesions, there are no pathognomonic signs to confirm the diagnosis. The exact diagnosis is based on the histology after complete surgical excision. An open surgical approach is considered the traditional method of complete resection; however, laparoscopic techniques have increasingly been employed. Diagnostic aspiration is discouraged due to the potential risk of seeding if the lesion is malignant. We present the case of a 51-year-old woman who underwent complete excision of a large right retroperitoneal cyst, histologically confirmed as PRSC with a review of the background and management options of this phenomenon.

Acute Gastric Dilatation With Ischemia and Perforation Requiring Emergency Total Gastrectomy: A Case of Suspected Abdominal Compartment Syndrome.

Acute gastric dilatation is an uncommon surgical pathology, leading to gastric ischemia, necrosis, perforation, sepsis, and death if untreated. While rare, the development of abdominal compartment syndrome is also a devastating complication of this entity. We present a case of a 42-year-old male with a history of gastric volvulus, presenting with severe acute abdominal distension and multi-organ failure. A diagnosis of acute gastric dilatation was made, with suspicion of abdominal compartment syndrome. Emergency laparotomy was performed when nasogastric decompression failed. Total gastrectomy without anastomosis was performed due to the patient's hemodynamic instability. However, he demised shortly after on the operating table. This case report demonstrates that even with rapid diagnosis and management, acute gastric dilatation continues to be associated with high mortality.

Gender Influence on Abdominal Aortic Aneurysm Surgery in a Caribbean Population.

Female patients with abdominal aortic aneurysms (AAAs) are usually less common and older than their male counterparts. We report on AAA disease in a Caribbean nation with respect to gender and review their outcomes relative to the male population. Data were collected prospectively and analyzed retrospectively for patients with AAAs who underwent surgery from 2001 to 2018. Sixty patients were diagnosed with AAA with 44 going on to have surgical repair of which 35 were males, aged 61 to 89 (mean age 73.4 years). Nine women ages 44 to 74 years (mean age 60.8 years) had surgical intervention, three being between 40 and 49 years. The size of aneurysms in these patients ranged from 4.3 to 11.0 cm in diameter (average 6.95 cm), female patients having an average diameter of 6.7 cm. Of the 44 patients, 43 underwent open and one endovascular repair. Thirty-three were elective cases and 11 were ruptured with 32 aorto-aortic and 13 aorto-iliac repairs. There were nine fatalities, three elective and six ruptured, with only one being female. Women had similar outcomes to men in all age groups with young patients having good results. Female AAA patients are usually older, undergo less surgical procedures especially if endovascular, and have worse outcomes than their male counterparts. Our study showed that the females were younger but had similar outcomes to the male patients. The female Caribbean patients may present at much younger ages than in continental populations and this may be due to genetic, ethnic, or lifestyle factors.

Necrotizing Fasciitis: Myalgia Is Diagnostic? A Case Series and Literature Review.

Necrotizing fasciitis, commonly known as "flesh-eating disease," is an aggressive soft tissue infection that destroys the fascia, subcutaneous tissue, and skin. Specific clinical features (crepitus or radiologic features of gas in tissues) either appear late or are of poor sensitivity. Thus, a high index of clinical suspicion is required for early diagnosis and prompt treatment, which are the best methods of minimizing its high associated morbidity and mortality. We present 3 cases to demonstrate diagnostic difficulties and challenges in management and highlight the feature of pain on muscular activity.

Necrotizing Soft Tissue Infections of the Breast: A Potentially Lethal Surgical Emergency.

Necrotizing soft tissue infection (NSTI) of the breast is an extremely rare event in surgical practice. It is considered the most aggressive form of soft tissue infection and a true surgical emergency. It is also associated with a high risk of mortality if not diagnosed promptly. Few cases have been documented in the literature; the exact etiology and risk factors vary from those involving the limbs, trunk, and perineum. Early recognition, prompt surgical treatment, and broad-spectrum antibiotic therapy are crucial for reducing morbidity and mortality. These reports present cases of NSTIs in breasts with unique etiologies and challenges in their management.

Endovascular Revascularization and Outcomes of Critical Limb-Threatening Ischemia in Trinidad and Tobago: The EVENT Pilot Study-Challenges in a Limited-Resource, Caribbean Setting.

INTRODUCTION: This retrospective study investigated major adverse limb events (MALE) and mortality outcomes in critical limb-threatening ischemia (CLTI) patients with tissue loss after an endovascular revascularization-first (EVR-1st) strategy. METHODS: MALE and mortality were assessed in 157 consecutive patients with CLTI and tissue loss from June 2019 to June 2022 at the Eric Williams Medical Sciences Complex, Trinidad and Tobago. RESULTS: 157 patients underwent the EVR-1st strategy, of whom 20 were pivoted to immediate surgical revascularization (SR). Of the remaining 137 patients, successful EVR was achieved in 112, giving a procedural success of 82% and an all-comer overall success of 71%. The mortality and MALE rates were 2.7% and 8.9% at 2 years, respectively. Males and patients with previous major amputations were at significantly higher risk for MALE (p values of 0.016 and 0.018, respectively). There was a statistically significant difference in successful EVR for both Rutherford-Baker (RB) 5 (minor) and RB 6 (major) classifications: 63 (56%) vs. 5 (20%) and 49 (44%) vs. 20 (80%), both with a p value of 0.01. There were no differences in successful EVR amongst Wound, Ischemia, Foot Infection (WIfI) clinical stages. There were no differences in successful EVR amongst the Trans-Atlantic Inter-Society Consensus (TASC II) classifications. CONCLUSIONS: This study may prove clinically informative and applicable for an EVR-1st management strategy for high-risk patients with CLTI in a limited-resource, Caribbean setting. TRIAL REGISTRATION NUMBER: NCT05547022 (retrospectively registered).

Multicenter Study of Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the English-Speaking Caribbean.

Background Common bile duct (CBD) exploration to address choledocholithiasis is not widely practiced in the English-speaking Caribbean. This study sought to determine the frequency of laparoscopic CBD explorations in the English-speaking Caribbean and to document the stone clearance rates and short-term outcomes of this procedure. Methods We accessed records for all practicing laparoscopic surgeons in the English-speaking Caribbean who performed laparoscopic CBD explorations over a 10-year period from January 1, 2013, to June 30, 2023. The following data were extracted retrospectively from patient records: demographic details, operating time, stone clearance rates, retained stone rates, conversions, and complications. All data were analyzed with SPSS version 20 (IBM Corp., Armonk, NY). Results Over the 10-year study period, 35 patients underwent laparoscopic cholecystectomy and synchronous CBD exploration in Barbados, Cayman Islands, Guyana, Grenada, St Lucia, and Trinidad & Tobago. The procedure was performed at low volumes of only 0.7 procedures per surgical team per annum. The conversion rate to open CBD exploration was 13% and when laparoscopic CBD exploration was completed, it resulted in 96.3% stone clearance, 3.7% retained stones, mean hospitalization of two days, 9.7% minor morbidity, and no mortality. Conclusion Laparoscopic CBD exploration is feasible in the resource-poor Caribbean setting, and it yields good results, with 96.3% stone clearance rates, 9.7% minor morbidity, and no mortality. These results are better than those reported in Caribbean literature for stone extraction with endoscopic retrograde cholangiopancreaticography (ERCP).

A case of malignancy in a thyroglossal duct cyst--recommendations for management.

Thyroglossal duct cyst carcinomas are rare tumors with just more than 200 cases published to date. This is a case report of a thyroglossal duct cyst harboring an occult carcinoma for which a Sistrunk operation was performed. Histopathological examination revealed a papillary carcinoma arising from a thyroglossal duct cyst after which the patient underwent a total thyroidectomy. With current evidence-based guidelines lacking, we discussed some of the issues relevant to the surgical planning and postoperative management of such a patient.

Robot-Assisted Common Bile Duct Exploration in Trinidad & Tobago.

Although laparoscopic common bile duct exploration is a feasible and safe option for the operative management of choledocholithiasis, there has been a general reluctance to perform this procedure in Caribbean practice. This is largely because duct exploration is perceived to be difficult with laparoscopic instruments, and endoscopic retrograde cholangiopancreatography (ERCP) has become increasingly available. We report a case in which stones were extracted laparoscopically from the common bile duct, aided by the FreeHand® (Freehand 2010 Ltd., Guildford, Surrey, UK) robot, to show that the procedure is feasible and safe in the Caribbean environment.

Small Bowel Obstruction Caused by an Aggressive Weight Loss Diet in a Patient With No Predisposing Factors.

Phytobezoars are a well-documented cause of small bowel obstruction. Previous reports include patients who have predisposing factors such as gastric surgery, diabetes mellitus, or poor dentition. Consequences of extreme dieting have also been reported, but a resultant phytobezoar and life-threatening bowel obstruction are rare. We present a case of phytobezoar solely due to a diet inordinately high in fiber.

Massive Rectal Hemorrhage From a Stercoral Ulcer.

Massive lower gastrointestinal (GI) bleeding from stercoral ulcers is exceedingly rare. We report a case of a middle-aged man who presented with progressively deteriorating neurologic function with constipation and subsequent massive GI bleeding per rectum. While an uncommon cause of GI bleeding, such patients require rapid resuscitation and timely diagnosis of these ulcers since the usual management of such cases will be futile and harmful due to potentially inappropriate surgical bowel resection.

Abrikossoff Tumor Clinically Mimicking Carcinoma in Accessory Axillary Breast Tissue.

Abrikossoff tumors are rare benign soft-tissue lesions also known as granular cell tumors (GCT). The histogenesis of these tumors was initially considered to be myogenic but recent studies have revealed a neuroectodermal origin. GCTs of the breast may mimic breast carcinoma based on the triad of radiological, clinical, and pathological features. This hallmark trait lends to the misdiagnosis of these tumors and their subsequent inappropriate management. We report a rare case of a 28-year-old female patient with an accessory axillary breast GCT. The diagnosis, histogenesis, and management of Abrikossoff tumors of the breast are discussed.