Characteristics and Ethnic Distribution of Aortic Aneurysms in a Caribbean Cohort.

BACKGROUND: There is a paucity of data regarding relationships between patient demographics and aneurysm characteristics in the West Indies. With this in mind, a retrospective cross-sectional review was conducted analyzing the computed tomography aortogram reports/images of 273 aortic aneurysms. METHODS: Data were collected and analyzed on ethnicity, size, type, morphology, presence and maximum size of thrombus and aneurysm location, demographics, and clinical presentation with correlations. RESULTS: There were 273 patients with aortic aneurysms giving an incidence rate of 4.33 per 100,000 people per annum. Statistically significant associations were noted with age, gender, and ethnicity. All false aneurysms were male (p = 0.004). The average size of aortic aneurysms being 0.7 cm larger in males than females (p < 0.001). Females were more likely to present with rupture (p = 0.001). Thrombus was more likely in males, Black and mixed races, and in the 8th decade (p < 0.001). Mean age of presentation was the highest in East Indians at 78 than the other ethnicities (Chinese: 65, Black: 70, mixed: 71, White: 73). CONCLUSION: Aortic aneurysmal disease is increasing in Trinidad and the Caribbean. Infrarenal fusiform aneurysms are the most common types with many significant differences based on age, gender, and ethnicity in the Caribbean population.

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.

TEVAR for symptomatic Stanford B dissection: a systematic review of 30-day mortality and morbidity.

BACKGROUND: The aim of this study was to determine morbidity and 30-day mortality rates of thoracic endovascular aortic repair (TEVAR) for Stanford B dissection over a 16-year period and determine if these rates have improved with better stent-graft technology and surgical technique. METHODS: Electronic databases were searched in all languages and a systematic review conducted. A comparison of the early (1998-2007 = 787 patients) and later (2007-2013 = 787 patients) halves of the patient population was done. Studies were chosen based on availability of details regarding morbidity and mortality. Ambiguous studies were excluded. RESULTS: A total of 69 suitable studies published between 1998 and 2013 (1,574 patients) were examined including 1 randomized control trial, 55 retrospective studies, 3 prospective, 1 mixed, and 9 case reports. Overall mortality and morbidity rates for TEVAR was 8.07% (n = 127) and 30.8% (n = 485), respectively. The stent-graft-related death rate was 6.20% (97 cases excluding medically related deaths). The endoleak rate was 5.9% of which most were type I. Major complications include stroke (2.7%), paraplegia (1.9%), partial thrombosis of false lumen (2.5%), retrograde type A dissection (3.1%), visceral malperfusion (2.0%), conversion to open intervention (1.9%), and secondary intervention (4.1%). The stent-graft-related mortality rate increased in the 2007 to 2013 group compared with the 1998 to 2007 group (56.2 vs. 24% of patients who died; p < 0.05). There was also an increase in the overall morbidity rates from 25% (1998-2007) to 36.6% (2007-2013) but did not reach statistical significance p > 0.05. CONCLUSION: Mortality and morbidity rates for TEVAR seemed to have increased over the past 16 years despite improved technology and surgical technique. This may be explained by the increasing liberal use of TEVAR intervention and quite possibly better reporting. The current data are highly heterogenous making it difficult for solid conclusions to be drawn. The only way forward is through better data registries and well-designed clinical trials.

Association between the appendix and the fecalith in adults.

BACKGROUND: We sought to determine the association between the presence of a fecalith and acute/nonperforated appendicitis, gangrenous/perforated appendicitis and the healthy appendix. METHODS: We retrospectively analyzed appendectomies performed between October 2003 and February 2012. We collected data on age, sex, appendix histology and the presence of a fecalith. RESULTS: During the study period, 1357 appendectomies were performed. Fecaliths were present in 186 patients (13.7%). There were 94 male (50.5%) and 92 female patients, and the mean age was 32 (range of 10-76) years. The fecalith rate was 13%- 16% and was nonexistant after age 80 years. The main groups with fecaliths were those with acute/nonperforated appendicitis (n = 121, 65.1%, p = 0.041) and those with a healthy appendix (n = 65, 34.9%, p = 0.003). The presence of fecaliths in the gangrenous/perforated appendicitis group was not significant (n = 19, 10.2%, p = 0.93). There were no fecaliths in patients with serositis, carcinoid or carcinoma. CONCLUSION: Our data confirm the theory of a statistical association between the presence of a fecalith and acute (nonperforated) appendicitis in adults. There was also a significant association between the healthy appendix and asymptomatic fecaliths. There was no correlation between a gangrenous/perforated appendix and the presence of a fecalith. The fecalith is an incidental finding and not always the primary cause of acute (nonperforated) appendictis or gangrenous (perforated) appendicitis. Further research on the topic is recommended.

CONTEXTE: Nous avons voulu examiner le lien entre la présence d'un fécalome et l'appendicite aiguë/non perforée, l'appendicite gangreneuse/perforée et un appendice sain. MÉTHODES: Nous avons analysé de manière rétrospective les appendicectomies effectuées entre octobre 2003 et février 2012. Nous avons recueilli des données sur l'âge, le sexe, l'histologie de l'appendice et la présence d'un fécalome. RÉSULTANTS: Durant la période de l'étude, 1357 appendicectomies ont été effectuées. Des fécalomes étaient présents chez 186 patients (13,7 %). L'étude regroupait 94 hommes (50,5 %) et 92 femmes; l'âge moyen était de 32 ans (entre 10 et 76 ans). Le taux de fécalome était de 13 % à 16 % et non existant après l'âge de 80 ans. Les principaux groupes porteurs de fécalomes étaient ceux qui présentaient une appendicite aiguë/non perforée (n = 121, 65,1 %, p = 0,041) et ceux dont l'appendice était sain (n = 65, 34,9 %, p = 0,003). La présence de fécalomes dans le groupe souffrant d'appendicite gangreneuse/perforée s'est révélée non significative (n = 19, 10,2 %, p = 0,93). Les patients qui souffraient de sérosite, de carcinoïde ou de carcinome ne présentaient pas de fécalomes. CONCLUSION: Nos données confirment la théorie d'un lien statistique entre la présence d'un fécalome et une appendicite aiguë (non perforée) chez l'adulte. On a également observé un lien significatif entre un appendice sain et des fécalomes asymptomatiques. On n'a observé aucune corrélation entre un appendice gangreneux/perforé et la présence de fécalomes. Le fécalome est une observation accessoire qui n'est pas toujours la principale cause de l'appendicite aiguë (non perforée) ou de l'appendicite gangreneuse (perforée). Une recherche plus approfondie à ce sujet est recommandée.

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.

Superficial palmar arch aneurysm secondary to blunt trauma: Bag of ice versus bare hand!

A 45-year-old male prisoner was referred to the orthopedic outpatients clinic after he sustained a blunt palmar injury when he tried to break-up a bag of ice with the volar aspect of his hand. A few months later a pulsatile expansile mass developed at the site of blunt trauma affecting flexion and extension of the fingers and inability to hold objects. A computed tomography angiogram confirmed the mass to be a true aneurysm of the superficial palmar arch 3 cm in size. The patient was referred to the vascular surgery department where the aneurysm was dissected and ligated with removal of the thrombus with no reconstruction of the vessel necessary. The patient had an uneventful recovery with return of full function.

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.

Breast Carcinoma Receptor Expression in a Caribbean Population.

Trinidad and Tobago are islands in the Southern Caribbean with a unique mix of races within the population consisting of East Indian (EI) (37.6%), Afro-Caribbean (AC) (36.3%), mixed (24.2%), and Caucasian, Chinese, Lebanese, Syrian, Amerindian, and Spanish groups accounting for 1.9%. It makes it suitable for a comparison of breast carcinoma receptor expression within a fixed environment. This study included 257 women with an age range of 28 to 93 years (mean = 57.2, standard deviation = 15.0), peak age group of 51 to 60 consisting of 105 EI, 119 AC, and 33 mixed descent. Invasive ductal carcinoma accounted for 88%, invasive lobular 9.7%, and ductal carcinoma in situ 2.3%. The triple-negative rates were 24.8, 33.6, and 30.3% for EI, AC, and mixed races, respectively, with the Pearson's chi-square test revealing statistical significance for the AC versus EI ( p < 0.001); AC versus mixed ( p < 0.001); and EI versus mixed ( p = 0.014) groups. The overall estrogen (ER), progesterone (PR), and human epidermal growth receptor (HER) expression negative rates were 52, 64, and 79%, respectively. Chi-square test of the following combinations: ER +/PR +/HER + ; ER +/PR +/HER - ; ER -/PR -/HER + ; ER +/PR -/HER + ; ER +/PR -/HER - ; ER -/PR +/HER + ; ER -/PR +/HER- revealed no statistical differences ( p = 0.689).

Extrahepatic biliary obstruction secondary to metastatic esophageal squamous cell carcinoma: An unusual presentation of Courvoisier's law.

Courvoisier's law states, "In the presence of jaundice and a palpable bladder, the cause is unlikely to be due to stone". Although esophageal squamous carcinoma is known to spread to celiac nodes, there is no description in the literature with it presenting and mimicking the above findings in Courvoisier's Law.

Achenbach's Syndrome Revisited: The Paroxysmal Finger Hematoma May Have a Genetic Link.

Achenbach's syndrome describes the sudden occurrence of bruising, pain and swelling of one or more digits of the hand involving the volar aspect of the proximal and middle phalanges. Also known as the paroxysmal finger hematoma, it presents in dramatic fashion, sometimes with a prodrome of tingling, itching or numbness but despite its dramatic presentation, all investigations are normal. Routine blood investigations, as well as coagulation and thrombophilia screens are all negative as are vascular imaging and echocardiography. The diagnosis is solely clinical. Due to the nature of its presentation, almost all patients are referred for an urgent vascular consultation but the condition resolves spontaneously usually within 2-3 days, although the discoloration may persist for longer. Its appearance usually leads clinicians to start anticoagulation in the belief that it may progress but, in fact, it settles as quickly as it appears. Though there are episodic cases which recur years later, it is generally self-resolving with no complications nor residual morbidity. Although the etiology was previously unknown, there is now a recognized genetic link. Genes related to the acute phase reactive proteins and the coagulation and complement cascades appear to be linked to Achenbach's syndrome. This evidence may explain why only certain individuals seem prone to this acutely painful, bruising disorder. We review this interesting disorder and compare patients from the tropical Caribbean region with similar cases from the temperate United Kingdom and discuss whether there are climatic variations in presentations.

Lessons Learned after Iatrogenic Complete Transection of the Right Common Carotid Artery with Segmental Vessel Loss.

Carotid arterial injuries occur in 5-6% of persons with penetrating trauma. Complete transection is rare in civilian practice and is most often due to penetrating injuries. Complete transection as an iatrogenic complication is rare. We present a case where we were required to repair a complete transection of the carotid artery with segmental loss which occurred as an iatrogenic complication during thyroidectomy. We could find no previous reports of this type of iatrogenic complication. The lessons learned during the management of this case were the following: (1) surgeons should call for help early, (2) a multidisciplinary approach ensures that all options are considered, (3) adhere to surgical principles of proximal and distal control, (4) always use atraumatic clamps to control vessels, and (5) flow restoration should be attempted, leaving carotid ligation as the last resort.

Dermatofibrosarcoma protuberans associated with trauma: A case report.

A case of dermatofibrosarcoma protuberans (DFSP) in a 22-year old female associated with blunt trauma of the mid-upper back is presented in the current study with a review of the literature. DFSP is a rare slow growing sarcoma of the soft tissue most commonly seen on the trunk and upper extremities with a low to intermediate grade malignant potential, high chance of local invasion and a high local recurrence rate. The literature search revealed that both non-congenital mutation as well as trauma serve a role in the development of this dermal neoplasm, but the exact mechanism by which trauma may predispose to development of DFSP is unknown. However, it seems intuitive that chronic inflammation and stimulation of the immune system at a local level may trigger the immunopathologic changes that could lead to the malignant transformation of dermal cells. Future research into the relationship between trauma and DFSP on a cellular level is required, as there appears to be a direct link present.

Femoro-distal bypass in a 5-year old with blunt popliteal artery trauma: Considerations in a limited resource setting.

Blunt popliteal vascular injury in the paediatric population is exceedingly rare and in advanced trauma centres the management can be challenging. A case of blunt popliteal artery trauma in a 5 years old requiring distal bypass using reversed saphenous vein is herein described. It is noteworthy to mention the difficulties experienced in a limited resource setting, including limitations in small rural hospitals, inefficient timely transfer to specialised centres, inadequate numbers of highly trained surgeons in subspecialities such as microvascular surgery and finally ineffective support and rehabilitative services.

Extreme traumatic arteriovenous fistula of the upper limb.

Traumatic arteriovenous fistula with steal syndrome of the extremity is rare. A useful technique is herein described involving complete ligation of the fistulous connection with a distal bypass procedure done using reversed great saphenous vein to salvage the upper limb.

A historical perspective on the introduction of laparoscopic basic surgical training in the Caribbean and factors that contribute to sustainability of such training.

OBJECTIVE: To report the development of minimally invasive training courses and workshops in the Caribbean and specifically the establishment of the Basic Surgical Skills Course of the Royal College of Surgeons of England (RCSEng) in Trinidad with respect to their value toward Surgical laparoscopic or minimally invasive training in the Caribbean. DESIGN: & Methods: The literature written on laparoscopy in the region was reviewed and in particular that related to the minimally invasive training courses provided over the period 2004 to 2019 and the development of laparoscopic surgical training described from a historic perspective. The factors that contribute to sustainability of courses were identified. RESULTS: Laparoscopic surgical training courses were sporadically introduced into the Caribbean over the period 2004 to 2019 in countries including Barbados, Curacao, Guyana, St. Lucia, Jamaica and Trinidad & Tobago. These were timed and closely related to the establishment of the Caribbean College of Surgeons (CCOS) with the help of the Royal College of Surgeons of England. However, the only certified course introduced was the Basic Surgical Skills (BSS) course of the RCSEng into Trinidad in 2012. This has now been established as a recognised overseas centre by the RCSEng and provides the Intercollegiate BSS course annually forming a solid basis for trainees to learn safe surgical and laparoscopic skills prior to commencing formal surgical training. This has resulted in the sustainable development of minimally invasive training in Trinidad in particular. CONCLUSION: Laparoscopic skills courses and workshops have been established in the Caribbean for 15 years beginning circa. 2004 to 2019 and have grown in number and locations throughout the Caribbean. The RCSEng and the CCOS have been instrumental in the development process. Of note, the only recognised overseas training centre for Basic Surgical Skills Course was established in Trinidad & Tobago with the support of the RCSEng and seems to be the main contributor to the successful, regular maintenance of these and other minimally invasive courses in General Surgery, ENT, Gynaecology and other fields on an annual, sustainable basis.

Risk factors associated with amputation in civilian popliteal artery trauma.

Popliteal artery trauma is uncommon but is associated with a high risk of limb loss depending on the scenario involving blunt or penetrating trauma as well as the severity and extent of injury that has occurred. In our setting there is a significant amount of gang and civilian warfare resulting in Vascular Trauma. There were 32 patients over a decade who sustained traumatic injury to the popliteal artery consisting of 30 males (94%) and 2 females with an age range 16-59 years with a mean of 32. There were 20 cases of penetrating trauma (63%) and 12 cases of blunt trauma (37%). Of the penetrating trauma, 18 were due to gunshot wounds (GSWs) (90%) and 2 stabs. The majority (7/12; 58%) of blunt trauma was due to falls, and 42% (5/12) secondary to motor vehicular accidents (MVAs). In terms of extent of injury, 21 of 32 patients (65%) sustained an isolated popliteal artery injury, whilst 6 (19%) had injury to both the popliteal artery and vein and another 5 (16%) had combined popliteal artery, vein and nerve injuries. There were 14 cases with associated orthopaedic injuries: 7 posterior knee dislocations, 1 fracture/dislocation of the knee, 2 femoral fractures, 2 tibial plateau fractures and 2 tibia/fibula fracture. Methods of repair included 14 reversed vein grafts, 16 polytetrafluoroethylene (PTFE) grafts and 2 primary. The overall amputation rate was 28% (9 patients). Of the penetrating trauma patients 25% required amputations composed of 5 GSWs, 33% of the blunt trauma patients required amputations. It was noted that factors associated with (but not statistically significant) poor outcomes included combined artery/vein injury, artery/vein/nerve injury, concomitant fracture/dislocation and delayed transfer to a Vascular Surgery Unit. The type of graft or repair did not affect outcome. The incidence of popliteal artery trauma was calculated at 2.46 per 100,000 population per year.

Distal-to-Snuffbox Arteriovenous Fistula.

The dogma for optimal arteriovenous fistula (AVF) creation is based on starting as distally as possible on the upper limb and progressing proximally. We herein present our findings of an AVF that is as distal as possible on the hand. To document primary patency rates of the distal-to-snuffbox AVF. A 10-year prospective study (2006-2016) involving 31 patients whose distal cephalic vein diameter was ≥3 mm with a normal Allen's test was conducted. Patients were excluded if the radial artery in the wrist was highly calcified, the cephalic vein did not dilate more than 3 mm with proximal compression, and there was previously failed AVF of the limb or previous trauma to the limb. The procedure was performed under local anesthetic, and the anastomosis performed with a 6.0 polypropylene suture in an end-to-side fashion. Thirty-one patients with end-stage renal disease underwent distal vascular access using the distal-to-snuffbox (Hitchhiker's) AVF (HAVF). During follow-up, eight patients died with an adequately functioning HAVF. The primary patency rates at 12, 24, 48, and 60 months were 90, 87, 85, and 82%, respectively. Failure occurred in six (19%) cases over the follow-up period, two in the first 2 weeks and four over a span of 60 months. Conclusion The creation of radiocephalic AVFs in the first web space, distal to the tendon of the extensor pollicis longus, serves as a viable option with acceptable success rates. This allows the surgeon more options with proper patient selection for this procedure.