Acute hiatal hernia with oesophageal perforation following Heller's operation

The unusual complication of acute hiatal hernia with oesophageal rupture following transthoracic oesophagomyotomy is described in 2 cases. Inadvertent disruption and widening of the oesophageal hiatus at the time of surgery coupled with increased intragastric and intra-abdominal pressure were the probable causes. The hiatus should be carefully inspected on completion of the myotomy and anatomical restoration performed if necessary in order to avoid this complication. Urgent repair and intravenous alimentation proved successful in the management of these patients. (Au)

The Development of the Jamaica Burn Programme - abstract

The Jamaica Burn Unit opened at the University Hospital, Mona in mid-1986. To date, it has treated 75 patients with severe burns ranging in age from 2 to 72 years. The Unit is the brainchild of Esso Standard Oil (Jca.) Ltd. and the Dept. of Surgery, U.W.I. It constitutes the nucleus of a broader based Jamaican burn programme. The project has become a co-operative venture of the private and public sectors with the involvement of the Minsitry of Health and, through them, Project Hope. In addition to the acute 4-bed unit at Mona, the programme includes facilities for reconstructive burn surgery, the training of health professionals in the care of burns and an outreach programme for the public in prevention and first aid. A formal, post-basic course for nurses was begun in 1987 at the University Hospital and, to date, 7 nurses have completed the course including 3 from Government Hospitals. In June this year, a 3-day Symposium on burn care was attended by over 190 health professionals. An outreach programme which began officially in 1987 is to be intensified over the next 9 months with more emphasis on the media and on the rural areas. In 1987, the Jamaica Burn Programme was recognized by the Public Relations Society of Jamaica and given its highest award for community service. The programme is administered by the Jamaica Burn Management Committee, an official group of professionals from the Health and Business arenas. This group meets every 3 months and it is to them that much of the success of the programme is due (AU)

Apudomas of the pancreas

Apudomas of the pancreas form an interesting group because of their varied presentation which is frequently related to clinical syndromes caused by production of one or more hormones. We have had experience with the management of the two commonest syndromes associated with endocrine tumours. The ability of these tumours to produce more than one hormone and to be part of the multiple endocrine adenopathy should encourage more intensive biochemical and histochemical examination of patients presenting with these syndromes (AU)

Spontaneous rupture of the normal colon

A case of spontaneous rupture of the colon in a previously asymptomatic patient is herein reported. At laparotomy, apart from the tear in the sigmoid colon, no other pathological problem was present. An awareness of the existence of this condition will lead to early diagnosis and management with improved morbidity and mortality. (AU)

Ruptured rectal prolapse

Rectal prolapse is not a common surgical disorder. The complication reported here, of evisceration of small bowel through a prolapsed rectum, is extremely rare and is the first case reported in the West Indies. Some of the features of rectal prolapse are described, and the surgical management of this particular complication is discussed (AU)

Primary aortoenteric fistula

One hundred and thirty-eight patients with abdominal aortic aneurysms were treated by aneurysmorrhaphy over an eleven-year period. Six patients, all male and aged 60 - 74 years, were found to have developed primary aorteonteric fistulae. Four patients presented with bleeding into the gastrointestinal tract in association with a tender abdominal swelling. In the other two cases, the aneurysm was discovered at emergency laparatomy for gastrointestinal haemorrhage. The presence of the fistula was confirmed at operation in five patients and at autopsy in one. Two patients died, one from a massive gastrointestinal haemorrhage to surgery, the other from sepsis complicated by adult respiratory distress syndrome and renal failure following operation (AU)

Benign colovesical fistulae

Two successfully treated cases of benign colovesical fistula are presented. The condition should be suspected whenever patients with colorectal disease develop urinary symptoms. Fllexible colonoscopy and lateral abdominal X-ray should be the initial investigations; but barium enema, cystoscopy and, rarely, CT scan may be necessary to confirm the presence of a colovesical fistula. Patients should be managed conservatively during the acute phase, and then be treated definitively by a single-stage bowel resection. Simple closure or resection and closure is used for the bladder defect. (AU)

Cancer of breast: a ten-year review at the University Hospital the West Indies

There has been no change in the number of new cases or in the age distribution of breast cancer seen at the University Hospital of the West Indies over the last 25 years. Although a higher proportion of the disease is diagnosed early, we still see a considerable number of patients with stages II and III disease. The histological type most frequently seen is infiltrating duct carcinoma which is known to have a much poorer prognosis than other variants. Clearly, our next line of investigation in the assessment of this disease must involve examination of survival statistics of our cases with special reference to the forms of therapy used (AU)

Penetrating wounds of the abdomen

The frequency of penetrating wounds seen in the University Hospital ofthe West Indies during a 3-year period, January, 1974, to December, 1976, is presented. Seventy-five patients had abdominal wounds. Abdominal stab wounds produced intra-abdominal damage in about half of the cases, but 77 percent of abdominal gunshot wounds resulted in visceral injuries. All gunshot wounds of the abdomen should be explored surgically but laparotomy should be performed selectively in patients with abdominal stab wounds (AU)

Leiomyosarcoma of the duodenum

Only two cases of leimyosarcoma of the duodenum have been documented by the Jamaica Cancer Registry to date. One patient presented with obstructive jaundice which is an unusual presentation of this tumour. He died on the ninth post-operative day due to necrotising entero-colitis. The other patient presented with rectal bleeding, anaemia and an abdominal mass. The lesion was treated with pancreatico-duodenectomy and he is alive, but with recurrence up to the date of reporting. Neither of the two cases was diagnosed pre-operatively. Surgeons should be aware of this lesion while operating for upper-intestinal bleeding or on patients with obstructive jaundice (AU)

Penetrating wounds of the thorax

A review of penetrating wounds of the chest seen at the University Hospital of the West Indies during the period January, 1974 to December, 1976, is presented. Haemothorax can be successfully treated by tube thoracostomy and underwater seal drainage. Emergency thoracotomy was necessary for bleeding in excess of 1,000 cc after tube thoracostomy, continued bleeding following tube thorascomy with associated signs of shock, a large entry wound, cardiac tamponade and associated inta-abdominal injury. All patients with cardiac tamponade who reached the hospital alive survived following thoracotomy and cardiorrhaphy (AU)

Leiomyosarcoma of the rectum

The only case of leimyosarcoma of the rectum seen at the University Hospital of the West Indies is reported. The natural history and pathology of this tumour are similar to those of smooth muscle tumours occurring elsewhere in the gut. When rectal leimyosarcoma invades adjacent organs such as the vagina and bladder, it may give rise to considerable morbidity. In addition, widespread metastases may occur. Aggressive surgical therapy is therefore warranted for early lesions if therapy is expected to be curative (AU)

Biliary ascariasis

Biliary ascariasis complicated by cholangitis is reported in a 23-year-old woman. Removal of a worm and cholecytostomy were performed. Residual worms were found in the bile ducts by post-operative cholecysto-cholangiography. These were successfully eradicated with oral antihelminthic therapy (AU)

Benign colovesical fistulae

Two successfully treated cases of benign colovesical fistula are presented. The condition should be suspected whenever patients with colorectal disease develop urinary symptoms. Fllexible colonoscopy and lateral abdominal X-ray should be the initial investigations; but barium enema, cystoscopy and, rarely, CT scan may be necessary to confirm the presence of a colovesical fistula. Patients should be managed conservatively during the acute phase, and then be treated definitively by a single-stage bowel resection. Simple closure or resection and closure is used for the bladder defect.

Primary aortoenteric fistula

One hundred and thirty-eight patients with abdominal aortic aneurysms were treated by aneurysmorrhaphy over an eleven-year period. Six patients, all male and aged 60 - 74 years, were found to have developed primary aorteonteric fistulae. Four patients presented with bleeding into the gastrointestinal tract in association with a tender abdominal swelling. In the other two cases, the aneurysm was discovered at emergency laparatomy for gastrointestinal haemorrhage. The presence of the fistula was confirmed at operation in five patients and at autopsy in one. Two patients died, one from a massive gastrointestinal haemorrhage to surgery, the other from sepsis complicated by adult respiratory distress syndrome and renal failure following operation

Colorectal cancer in Jamaica - Poster abstract

OBJECTIVE: This review was designed as a pilot study to collect data on colorectal cancer surgery which would provide the basis for conducting formal prospective data collection on the patterns of this disease and its clinical presentation. DESIGN AND METHOD: A comprehensive audit of all patients with a diagnosis of colorectal carcinoma was undertaken over a 2 year period (January 1996 to December 1997). RESULTS: A total of seventy-nine patients were studied. There were 47 females and 32 males. The median age was 64.5 years (range 19 to 91 years). The predominant presenting symptoms were abdominal pain in 44 patients (55.7 percent), change in bowel habit in 38 patients (48.1 percent) and rectal bleeding in 37 patients (46.8 percent). The presence of an abdominal mass in 18 patients was the most frequently detected sign. Rectal examination detected the presence of a mass in 14 (17.7 percent) patients. Forty-seven percent of patients present with anaemia. The most common location was the right colon in 21 patients (26.5 percent) followed by sigmoid colon in 15 (18.9 percent) and rectum in 14 (17.7 percent). Left and transverse colon accounted for 7 and 5 cases, respectively. Resection with restorative anastomosis was the most common procedure for primary disease with colostomy being performed infrequently (in 3 cases). Seventeen patients presented with advanced disease. There were 14 deaths, 10 due to metastatic disease and 4 from postoperative complications. Our findings indicate an increased incidence of right-sided colonic carcinomas which has also been reported by other recent series. Although this colorectal audit provides some information about the patterns of disease seen in our unit, further study of a larger group of patients will be necessary before accurate conclusion can be made. CONCLUSION: 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 indicate that the majority of patients presented with advanced right sided lesions that could have been detected earlier with an established screening programme.(AU)

Pancolo-mucosal proctectomy with ileo-anal anastomosis - abstract

Preservation of the ano-rectal spinchter and lower rectal muscle cuff following total colectomy and a mucosal protectomy with ileo-anal anastomosis (CMP - IAA) effectively removes all the debilitating, potentially malignant colonic mucosa and results in good to excellent continence. Since 1983 at U.H.W.I., Mona, five (5) patients have undergone CMP - IAA for colonic mucosal dysplasia and multicentric adenocarcinoma (1), familial polyposis coli (1), juvenile polyposis coli (1) and ulcerative colitis (2). Four out of five have had clousure of their temporary diverting ileostomy and all have good to excellent anal continence, with an average of 2 - 6 stools/day. There were no deaths and an unremarkable post-operative course was noted in all except one patient with over a 20-year history of steriod-controlled ulcerative colitis. She had a prolonged stormy post-operative course, rectal cuff abscess and resulting ileo-anal stricturing. Not withstanding this, she has good anal continence, but requires digital dilation. This initial experience of the U.H.W.I. group compares favourably with over 2,500 cases in the current literature and establishes CMP - IAA as the procedure of choice in this group of young, active patients (AU)

Oesophageal varices - abstract

The treatment of bleeding oesophageal varices remains a frustrating exercise for physicians and surgeons. At the University Hospital of the West Indies, during the period January 1971 to December 1982, 53 patients were admitted with bleeding oesophageal varices. The diagnosis was confirmed by barium meal, oesophagoscopy, surgery or at post-mortem. Thirty-nine of these were males. Their ages ranged from 11 to 81 years. Forty-two belonged to the 40 to 60-year age group. Initially, all patients were treated with blood transfusion, intravenous pitressin and the Sengstaken Blakemore tube. In 10 patients the bleeding stopped and they were discharged home. Of the remaining 43 patients, 29 died without surgery. Sixteen patients died within 3 days of admission, 7 patients were not fit for surgery and 6 refused operation. Fourteen patients underwent surgery. Eleven had an emergency surgical procedure to control bleeding and only 3 of these survived. Three patients had elective operations following conservative control of bleeding and all of them survived. The overall mortality form bleeding oesophageal varices of 70 percent reflects our difficulty in controlling bleeding adequately in the initial stages as a prelude to elective portal decompression in these patients. The reason for this are: (a) difficulty in monitoring the patients with Sengstaken-Blakemore tube on the general wards, and the frequent non-availability of the tube, (b) difficulty in obtaining adequate amounts of blood, and (c) lack of early surgical intervention in cases where bleeding is not controlled by conservative means. It is our belief that patients with acute variceal haemorrhage should be manged in an Intensive Care Unit. In this setting we are more likely to be able to control bleeding and to prepare the patient for elective surgery. We also need to develop a more aggresive approach to those patients whose bleeding is not promptly controlled and to advise surgical intervention before the general conditions of the patient deteriorates to a point where he is no longer fit for surgery (AU)

Treatment of low rectal carcinoma by transanal electrocoagulation

This study reports the first 13 cases of biopsy-proven low rectal carcinoma treated by transanal electrocoagulation using a locally manufactured instrument. At the University Hospital of the West Indies, over a 16-year period, 9 patients were treated for cure, six of whom have no clinical evidence of recurrence for one to 12 years. Four cases who were offered this procedure for palliation defaulted after a single treatment. Transanal electrocoagulation provides an additional option for treating patients with small, mobile low rectal cancers, following careful screening for evidence of nodal or distant spread. The procedure can also be used in the local control of disease in patients with distant spread or in whom a major operation is not feasible (AU)

Breast cancer in young women

Breast cancer is now the commonest malignancy among females in Jamaica. In 1985 a Breast Cancer clinic was established at the University Hospital of the West Indies (UHWI) and, because young age has been suggested to be an adverse prognostic factor, data collected during the first five years were analysed to establish the pattern of this disease in young women. Thirty of the 227 female patients seen at the clinic during this period were under age 40. Information was insufficient in one case and the remaining 29 formed the study group. Only three patients were less than 30 years of age, 15 being aged 35 to 39 years. Family history was negative in 16 of 24 cases. In 28 patients presentation was related to the finding of a mass. Treatment was by surgery with or without adjunctive therapy. Eight patients were assessed as stage I, eleven were stage II and nine were stage III. Of the 20 patients for less than five years, there were three deaths and eight were distant metastases. Two of the other nine patients had distant metastases. There may be several reasons including difficulty in accessing health care, attitudes to health care that delay diagnosis, and race, why in so many of the study group the presenting disease was advanced, but no information was available to suggest what role these factors might have played in our patients.(AU)