Acute Upper Limb Ischemia: Prompt Surgery and Long-Term Anticoagulation Prevent Limb Loss and Debilitation.

BACKGROUND: Acute upper limb ischemia is an uncommon clinical manifestation of thromboembolism seen predominantly in patients with atrial fibrillation. Treatment can be by conservative or surgical means but the consensus is that after conservative treatment, symptoms still persist. In this series, an attempt was made at limb preservation and return to functional capacity by early surgery in all patients diagnosed with acute limb ischemia. METHODS: Patients referred with upper limb ischemia (22) were stratified into non-acute (6) treated with anticoagulation alone and those with acute ischemia. Sixteen (16) patients, age range 30-92 years (median 62.4 years) comprising mainly females (13), had clinical evidence of severe ischemia and underwent immediate brachial embolectomy with postoperative anticoagulation. RESULTS: Sixteen patients underwent 20 embolectomies with immediate reperfusion of limbs and relief of symptoms. Two patients had two re-operations each due to recurrent symptoms but both recovered with good outcome, one going on to have an axillary-radial bypass. There was no limb disability nor limb loss, but one postoperative mortality. All other patients were seen at their 1-year review and at 5 years, eleven out of 15 patients were still alive with most resuming an active lifestyle and some returning to work. CONCLUSION: Good outcomes were obtained in this series in both the short and long term. Despite one mortality, there was no limb loss nor disability in a mainly elderly population. Prompt surgery and meticulous long-term anticoagulation reduced complications and improved limb salvage rates ensuring that patients had a good quality of life after surgery.

World's Oldest Case of Synchronous Bilateral Benign Phyllodes Tumors of the Breast: A Rare Occurrence.

Phyllodes tumors are rare fibroepithelial tumors of the breast. They account for less than 0.5% of breast cancers. Bilateral presentation is a rare event, and seems to be associated with the more benign subtype but, reports are scarce. It is more common to have multiple ipsilateral tumors or bilateral asynchronous presentations. However, bilateral synchronous phyllodes are seldom reported. A literature search has revealed only five cases of synchronous and one case of metachronous bilateral phyllodes tumor of the breast. The age ranges of these patients are between 16-42 years. We are reporting the world's first case of bilateral synchronous phyllodes tumor of the breast in a patient over the age of 50 years.

Surgical glove use for specimen removal in laparoscopy, the cheapest available: a prospective study.

Despite the proven benefits of laparoscopic surgery, it is indeed very costly. The aim of our study was to show an effective way to reduce one of the costs. Between January 2012 and December 2018, we used sterile unpowdered latex-free surgical gloves for specimen retrieval in 243 selected cases of laparoscopic cholecystectomy and appendectomy. The mean retrieval time was 6.7 ± 3.6 min. All procedures were performed safely. Minor wound infection was noted in three patients but there was no case of port site hernia in our series. We conclude that specimen retrieval using sterile, unpowdered, latex-free surgical gloves is safe, effective and cheap. No special additional preparation is required.

Largest giant juvenile fibroadenoma of the breast.

Juvenile giant fibroadenoma is a rare benign tumour of the breast accounting for 0.5% of all fibroadenomas. The presentation can be very dramatic and may result in breast deformity and may mimic a rare malignant tumour. It is indeed a great challenge to provide the best treatment for these patients in terms of clinical and psychological care. Meticulous surgical planning is required to ensure a fine balance between adequate resection and the best cosmetic outcome for a developing breast. Every effort should be made to preserve the developing breast irrespective of the size of the tumour as it is in this case. We report the world's largest juvenile fibroadenoma of the breast in a 16-year-old girl who presented to our hospital with a 28×25 cm mass on her left breast in which breast conservation was done. A detailed literature search and management of these lesions are discussed.

Mango seed causing acute large bowel obstruction in descending colon-world's first reported case.

INTRODUCTION: Phytobezoars are a very rare cause of large bowel obstruction. Mango seeds as a phytobezoar causing large bowel obstruction have not been reported in the English literature. PRESENTATION OF CASE: We present the case of a 69 years old female who presented to us with clinical and radiological signs of acute large bowel obstruction. On laparotomy, it was noted that mango seeds as a phytobezoar was responsible for the obstruction in the descending colon. DISCUSSION: Phytobezoars are a rare but known cause of small bowel obstruction. Large bowel obstruction is even rarer. The literature has documented a few cases of small bowel obstruction caused by mango seeds but none for large bowel obstruction. The most frequent reported sites of large bowel obstruction are the sigmoid colon and recto-sigmoid junction. However, phytobezoar causing descending colonic obstruction without any pre-existing underlying pathology has not been reported. CONCLUSION: The association of bezoar with acute large bowel obstruction is a very rare however; it must be entertained in the differential diagnosis of any large bowel obstruction. Early diagnosis and treatment can avoid lethal complications. Our case being the first case of mango seeds phytobezoar in descending colon with acute large bowel obstruction; signifies its importance for reporting in the English literature.

Primary greater omental GIST presenting with acute intra-abdominal haemorrhage.

Primary omental gastrointestinal stromal tumours (GISTs) are classified as extra-GISTs with a reported incidence of <1% of all GISTs. There are only a few cases in the English literature reporting omental GIST with none reporting acute intra-abdominal haemorrhage as a presenting feature. We report a case of a 67-year-old man who presented with haemorrhage from a primary omental GIST requiring emergency laparotomy.

Synchronous volvulus of the sigmoid colon and caecum, a very rare cause of large bowel obstruction.

Colonic volvulus usually occurs as a single event that can affect various parts of the colon. The usual sites affected being the sigmoid colon (75%) and the caecum (22%). The phenomenon of multiple sites simultaneously undergoing volvulus is an extremely rare occurrence. Synchronous double colonic volvulus is extremely rare and to the best of our knowledge, this is the 4th reported case of simultaneous sigmoid and caecal volvulus in the English literature. The clinical presentation and the radiological findings are that of large bowel obstruction. Classic radiological findings may not be present or may be overlooked due to its rarity. Treatment of this condition is early surgical intervention to prevent the sequalae of a colonic volvulus and its associated mortality. We report a case of an 80-year-old man with synchronous volvulus of the sigmoid colon and caecum.

Spontaneous fistulisation and drainage of a pyogenic liver abscess into the stomach in an adult patient with sickle cell disease.

Spontaneous endoluminal drainage of a pyogenic liver abscess is a rare phenomenon. Similarly, there are only a few cases in the English literature describing hepatic abscesses as an unusual complication of sickle cell anaemia. Having these two phenomena occurring in the same patient is truly a rarity. We describe a case of a 45-year-old man with homozygous sickle cell anaemia who presented to our institution with a pyogenic liver abscess. He had spontaneous drainage of the abscess after spontaneous fistulisation, with the stomach obviating the need for percutaneous drainage.

Epidemiology of diabetic foot infections in an eastern Caribbean population: a prospective study.

INTRODUCTION: This study evaluates the epidemiology of diabetic foot infections in an Eastern Caribbean nation in order to direct public health preventive measures. METHODS: We prospectively identified all patients with diabetic foot infections who were admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. A questionnaire was used to collect data on demographics, patient knowledge, avoidance of risk factors for chronic diseases (a proxy to unhealthy lifestyles), and glycosylated hemoglobin measurements on admission as an index of blood glucose control. The data were analyzed with statistical software. RESULTS: There were 446 patients with diabetic foot infections (mean age = 56.9 years, standard deviation = 12.4 years). Most patients had Type 2 diabetes (93.3%) and were of Indo-Trinidadian (49.1%) or Afro-Trinidadian (41.7%) descent. There were preexisting complications of diabetes in 82.9% of patients with Type 2 diabetes: foot infections requiring hospitalization (70.2%), ischemic heart disease (32.5%), renal impairment (13.7%), and retinopathy (22.1%). Despite most patients claiming compliance with treatment, 75% had glycosylated hemoglobin levels above 7.1% at presentation, and 49.3% continued unhealthy lifestyles. Despite the high prevalence of diabetic complications at admission, and despite 70% having had previous hospitalization for treatment of foot infections, only 57.4% of patients reported ever being counseled or taught about foot care by medical personnel. CONCLUSIONS: There is room for improvement in public health strategies to prevent diabetic foot complications in this setting. Such strategies should focus on patient education with emphasis on lifestyle modification and compliance with medical therapy.

Secondary prevention of diabetic foot infections in a Caribbean nation: a call for improved patient education.

Most countries have instituted measures to limit the complications of diabetes. We evaluate secondary prevention strategies for diabetic foot infections in a Caribbean country. We performed a prospective questionnaire study evaluating all patients admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. Primary study end points were the number of patient-detected injuries and the time interval between injury and presentation. Secondary end points included the practice of regular foot inspection (≥2 foot examinations per week) for early detection and the use of self-directed nonmedical therapies to treat foot infections. There were 446 patients admitted with diabetic foot infections at an average age of 56.9 ± 12.4 years. Three hundred and fifty-six (80%) were previously hospitalized with foot infections and 226 (51%) had already sustained end organ injury from diabetes. There were 163 (36.6%) patients walking barefoot at the time of injury and 189 (42.4%) had footwear-related injuries. In 257 (57.6%) cases, patients identified their foot injury shortly after the event. Despite early detection, they presented to hospital after a mean interval of 6.2 ± 5.03 days, with 78 (30.4%) having tried some form of home therapy first. Overall, 190 (42.6%) patients did not practice regular foot examinations. There is room for improvement in secondary preventative measures for diabetic foot infections in this setting. Educational campaigns may be beneficial to educate diabetics on the dangers of walking barefoot, the importance of appropriate footwear, regular foot inspection, and the importance of seeking immediate medical attention instead of experimenting with home remedies.