International surgery: the development of postgraduate surgical training in Guyana.

BACKGROUND: Like many developing countries, Guyana has a severe shortage of surgeons. Rather than rely on overseas training, Guyana developed its own Diploma in Surgery and asked for assistance from the Canadian Association of General Surgeons (CAGS). This paper reviews the initial results of Guyana's first postgraduate training program. METHODS: We assisted with program prerequisites, including needs assessment, proposed curriculum, University of Guyana and Ministry of Health approval, external partnership and funding. We determined the outputs and outcomes of the program after 2 years, and we evaluated the impact of the program through a quantitative/qualitative questionnaire administered to all program participants. RESULTS: Five residents successfully completed the 2-year program and are working in regional hospitals. Another 9 residents are in the training program. Twenty-four modules or short courses have been facilitated, alternating Guyanese with visiting Canadian surgical faculty members coordinated through CAGS. A postgraduate structure, including an Institute for Health Sciences Education and Surgical Postgraduate Education Committee, has been developed at the Georgetown Public Hospital Corporation (GPHC). An examination structure similar to Canada's has been established. Hospital staff morale is greater, surgical care is more standardized and academic opportunities have been enhanced at GPHC. Four regional hospitals have welcomed the new graduates, and surgical services have already improved. Canadian surgeons have a greater understanding of and commitment to surgical development in low-income countries. CONCLUSION: Guyana has proven that, with visiting faculty assistance, it can mount its own postgraduate training suitable to national needs and will provide a career path to encourage its own doctors to remain and serve their country.

Minilaparotomy ureterolithotomy: the third world treatment of choice for ureteric calculi? - abstract

Since the development of stone shattering and endourological techniques for the management of renouretic calculi, open surgery has been replaced as a first time treatment option in major urological centres. However, there are significant economic implications for these advantages and also many Caribbean countries cannot offer specialist urological services. Minimal access surgery has been shown, in other situations, to result in minimal metabolic disturbance, little pain, short hospital stay and early return to work. We developed a minilaparotomy muscle-splititng incision to achieve these results in ureteric stones and studied it prospectively in consenting patients. We reported 82 manilap ureterolithotomies with a 4-7 cm skin incision, mean operating time 28 minutes (10 - 44) and a mean hospital stay of 42 hours (24 -72). Because a muscle splitting technique is used pain is minimal and time to resumption of work averaged 16 days (8 - 35). We believe that manilap ureterolithotomy offers significant advantages over many currently employed techniques. These include reduced cost, operating time and duration of postoperative recovery, no need for specialist operative training and equipment and improved cosmetic results. We recommend it as the treatment of choice for ureteric calculi in most Caribbean territories. (AU)

Minilaparotomy cholecystectomy: the Third World solution for gallstones - abstract

Although many authors view laparoscopic cholecystectomy as the treatment of choice for gallstones there is evident that it has probably caused more deaths and major postoperative morbidity than open cholecystectomy. The Medical Defence Union has reported increased claims for bile duct injury from laparoscopic cholecystectomy (LC). The technology is expensive and not readily available in third world countries. Because minilaparotomy cholecystectomy (MC) also minimally invasive and offers similar advantages to LC we studied it prospectively and report our experience. MC was performed in 160 consecutive patients through a 4.8 cm (3 - 6 cm) incision, with operating time of 35 minutes (18 - 80 ). No major ductal injury and no reoperation occurred. Patients were discharged after 38 hours (range 16 - 60 hours). The operating time is much shorter, hospital stay and postoperative morbidity similar to LC. Review of the world literature shows no clear advantage of LC over MC. Because MC is cheap, effective, requires no specialised training or expensive equipment and can be done by any competent surgeon in most hospitals in the developing world, we recommend it as treatment of choice for gall stones in the third world. (AU)

Sutureless closure of traumatic wounds - abstract

Traumatic wounds are one of the commonest problems presenting to Accident and Emergency Departments. The most popular method of skin closure is suturing. However, this requires suture material, sterile equipment, operating room, cleaning solution, local anaesthesia and an assistant. In the Third World Accident and Emergency Departments setting these may not be readily available. Because of our chance observation that tape closure without cleaning and anaesthesia produced good healing in traumatic wounds we subjected the technique to a prospective analysis in consenting patients. A total of 147 lacerations, 8 cm long (range 2-17 cm) were closed with adhesive tape without cleaning the wounds. Wounds with obvious gross contamination and particulate matter were excluded. On follow up visits at 5 and 10 days, the sepsis rate was 1.36 percent and overall complication rate 2.7 percent. Patient satisfaction was excellent as they had a very short wait for treatment, no injections or suturing and no need for suture removal. Tape closure is associated with less wound sepsis than suturing. As we found, the results compare favourably with suturing. Because it is cheaper, quicker, requires no instruments or special facilities we recommend it for the treatment of traumatic wounds. (AU)

The management of benign prostatic hypertrophy(BHP): a Caribbean perspective

Benign prostatic hypertropy (BPH), which causes urinary obstruction, is a prostatic response to 5-hydroxy testosterone produced from testosterone by 5 O reductase. Blockade of 5 O reductase activity by Finasteride prevents BPH. Finasteride, now available, is expensive but, if affordable, is a real option for the patient with early BPH. We do about 100 transurethral resections of prostate (TURP) annually (TUIP/BNI are excluded). Eighty percent (80 percent) of these men present in acute retention of urine with an indwelling Foley catheter. These patients need urgent removal of an obstructive prostate. We offer most of these men a TURP. Two years ago we presented our early results, at CCMRC, of IPVP before TURP. We showed then that transrectal IPVP halved blood loss during TURP in the small prostate (<50 g). We continued the study and reported the use of IPVP in the large prostate of o 50 g. This group was studied without controls. Our justification was that the first part of our study with the small prostate group (done with controls) clearly demonstrated that IPVP significantly reduces blood loss during TURP. It would almost certainly be unethical to expose a number of patients with large prostate to a dangerous procedure simply to provide a controlled study. We now routinely use IPVP in the prostate of 40g or larger. IPVP permits a safe, rapid TURP. Blood loss is considerably reduced and blood transfusion is not required. We keep the postoperative BP carefully controlled at the preoperative level using sublingual Nifedipine. We therefore reduce both the preoperative and the post-operative blood loss (AU)

Intraprostatic vasopressin: an aid to TURP - abstract

Intraprostatic vasopressin (IPVP) reduces the bothersome small vessel bleeding encountered during routine transurethral prostatectomy (TURP). Ten units vasopressin (VP) in 0.5 ml diluted with 4.5 ml normal saline are injected transrectally into the prostate gland. Thirty-eight consecutive patients with prostates assessed as smaller than 40 gm were studied. Nineteen patients were given IPVP and 19 were not. The results in the 19 IPVP study group were compared with those of the controls (no IPVP group). Blood loss was halved by a single intraprostatic injection of 10 units VP in 5 ml saline solution. This difference was statistically significant. The IPVP patients were the normal older age group men with hypertension and other cardiovascular diseases. They all tolerated the IPVP without any morbidity. The injection of IPVP makes TURP easier to do and to teach/learn because bleeding is markedly reduced. Blood transfusion will therefore be less often required. No patient in this series required blood transfusion (AU)

Intraprostatic vasopressin before TURP - abstract

Intraprostatic vasopressin reduces the bothersome small vessel prostatic bleeding encountered during routine transurethral prostatectomy. Ten units vasopressin in 0.5 ml diluted with 1.5 ml normal saine are injected transrectally into the prostate gland. A single injection suffices for the procedure. TURP proceeds rapidly and safely. Large amounts of prostate tissue can be removed. Less blood is lost and blood transfusion is therefore less often required (AU)

One-stage hypospadias repair - abstract

Hypospadias, a congenital defect of the penis, results in proximal opening of the meatus and often produces curvature (chordee) of the penis. Surgery for this is difficult; over 200 procedures have been described in search of the ideal solution. Because of hypospadias is relatively uncommon, a single West Indian surgeon is unlikely to have a very large experience, especially with the newer one-stage procedures. Thus we combined the experience of two surgeons using the same modified Duckett's procedure to report the results. Fifteen cases done were over 6 years, using the vascularised transverse preputial island flap. There were no cases of stenosis of the neourethra. Two fistulas (at the proximal anastomosis) needed minor surgical revision. Further modifications of the technique are recommended to minimise fistula formation (AU)

A simple approach to the disrupted posterior urethra - abstract

Road traffic, farm and forestry accidents result in numbers of patients with fractured pelvis and disrupted posterior urethra. These patients present a formidable challenge to the urological services. A simple repair of the disrupted posterior urethra is presented. It avoids any difficult extensive perineal dissection which can injure an already compromised sphincteric mechanism, requires no special instruments and is easily performed and taught to others. The technique is a modification of the Blandy-Leadbetter 2-page posterior urethroplasty and utilizes a novel, simple method of flap introduction and fixation. Five men had successful repair, in that they can control passage of urine and are free of drainage catheters. Two of the 5 have proceeded to successful second stage repair and control the passage of urine via the penis. One of the 2 is able to ejaculate normally (AU)

Management of post-operative urinary tract fistula - abstract

This paper presents nine patients with urinary tract fistula repair done over a two-year period. All followed gynaecological/obstetrical trauma. Five patients suffered uretero-vaginal fistula; four patients vesico-vaginal fistula. The diagnosis was made by inspection of the introitus followed by an intravenous urogram, and a cytoscopy preceding the repair. A simple two-layer closure of the vesico-vaginal fistula and non-refluxing reimplementation of the proximal ureter in ureter-vaginal fistula was performed. A Foley catheter (bulb not inflated) is tied in for 12 days after the vesico-vaginal fistula repair and seven days after ureteric implantation. Antibacterial therapy is provided during the period with the in-dwelling catheter. Operation was done at three weeks after the injury rather than the conventional three months; this approach is psychologically kinder and technically no more difficult. Six women healed without complications; two healed after further simple intervention. One patient died after a flap interposition reoperation; post-mortem examination did not reveal the cause of death. Although we should prevent fistulae rather than attempt their repair, this is not always possible in the presence of fibrosis that follows severe recurrent pelvic sepsis (AU)

Management of post-operative urinary tract fistula - abstract

Urinary fistula is a tragedy. We present 8 patients, 33 to 49 yrs. of age, without malignancy, seen over a 16-month period, who had post-operative urinary tract fistulae. The antecedent surgery was gynaecological/obstetrical in each case. In 6 patients, the fistulae followed abdominal hysterectomy, and in 2, it followed caesarean section. The diagnosis was made by simple clinical inspection of the introitus to confirm urinary leakage; this occurred 2 to 8 days after surgery. Intravenous urograms were done to identify ureteric damage specifically, and provide information on the integrity of the upper tracts. Four women had vesico-vaginal fistulae, 3 had ureterico-vaginal fistulae and one had both bladder and ureteric damage. The urinary tract fistulae were repaired at three weeks rather than at 3 months, the conventional time for repair. We used a z-layer repair for the vesico-vaginal fistula (longitudinal vaginal and transverse vesical), using 20 or 30 chromic catgut. Ureteric damage was managed by a non-refluxing reimplantation procedure. The Foley balloon was not inflated, and the catheter was carefully observed to ensure free drainage. Five healed without complication; one ureterico-vaginal fistula developed abdominal leakage due to a blocked catheter, which healed after catheter change: 1 vesico-vaginal repair leaked when the catheter was removed at 14 days post-operatively, recatherisation for three weeks was successful; and in one patient, the procedure failed. In this last patient, the fistula recurred after her first repair; she remained dry for 6 weeks after a further attempt but then the fistula recurred (AU)

Interstitial cystitis - abstract

Urinary tract infection is common in the female patient. Most often, the specific bacterium is identified and appropriate antibacterial therapy instituted. There is a group of women, however, with clinical features indistinguishable from those of bacterial urinary tract infection, but in whom no bacterium can be grown with conventional culture techniques. We treated twenty-four women in two years. Presenting features included painful dysuria, frequency, which was often embarassing and incapacitating, haematuria, pyrexia, supra-pubic pain with fullness, and low back pain. Their mid-stream urines did not yield any significant bacteriuria. Cystoscopy was performed on all patients and the characteristic finding, although not pathognomonic for this condition of petechial haemorrhage on bladder decompression, after maximal filling under general anaesthesia, was found. All patients showed some improvement after hydrostatic bladder dilatation (done as part of cystoscopic study) under parenteral bolus antibiotic cover. It is essential that the cystoscopic study be done under general anaesthesia to allow for maximal bladder filling. Interstitial cystitis is a lower urinary tract disease. The upper tract seems in no way affected. The basic underlying abnormality is still not known (AU)

Bilateral hydrocoele and spermatogenesis - abstract

Hydrocoele, a common problem in Guyana, is regarded as mainly of nuisance value. We therefore investigated the effects of hydrocoele on seminal fluid analyses of patients (20-48 yrs) who had bilateral hydrocoele for 6 months to eight years. Three separate preoperative masturbation specimens were collected into glass jars and analysed within one hour from eight patients. Similar specimens were analysed within 3 months and after 3 months of Lord's repair of their hydrocoeles. The quantity of fluid at operation was measured. In five patients where each sac contained more than 100 ml (125-825 ml), the sperm count was consistently less than 20 million/ml and motility was less than 50 percent. The lowest counts and motility were seen in patients with long-standing hydrocoeles. In three patients, one of the two sacs contained less than 25 ml. The sperm count averaged 70 million/ml and motility was approximately 60 percent. Cross seminal fluid volume was similar in the two groups. Seminal analysis returned to preoperative or improved levels within 3 months. These findings suggest that hydrocoele is a potential cause of infertility and that early operation may preserve spermatogenesis (AU)