Whipple's pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago.

BACKGROUND: Many authorities advocate for Whipple's procedures to be performed in high-volume centers, but many patients in poor developing nations cannot access these centers. We sought to determine whether clinical outcomes were acceptable when Whipple's procedures were performed in a low-volume, resource-poor setting in the West Indies. AIM: To study outcomes of Whipple's procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. METHODS: This was a retrospective study of all patients undergoing Whipple's procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. RESULTS: This center performed an average of 11.25 procedures per annum. There were 72 patients in the final study population at a mean age of 60.2 years, with 52.7% having American Society of Anesthesiologists scores ≥ III and 54.1% with Eastern Cooperative Oncology Group scores ≥ 2. Open Whipple's procedures were performed in 70 patients and laparoscopic assisted procedures in 2. Portal vein resection/reconstruction was performed in 19 (26.4%) patients. In patients undergoing open procedures there was 367 ± 54.1 min mean operating time, 1394 ± 656.8 mL mean blood loss, 5.24 ± 7.22 d mean intensive care unit stay and 15.1 ± 9.53 d hospitalization. Six (8.3%) patients experienced minor morbidity, 10 (14%) major morbidity and there were 4 (5.5%) deaths. CONCLUSION: This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures. Low volume centers in resource poor nations can achieve good short-term outcomes. This is largely due to the process of continuous, adaptive learning by the entire hospital.

Trauma surgery via distance mentoring: A model inspired by the 2020 pandemic.

When the COVID-19 pandemic unfolded in March 2020, surgical care was impacted globally. The developing nations in the Caribbean were unprepared with fragile, resource poor healthcare systems. A series of rapid policy changes in response to the pandemic radically changed surgical care and prevented the usual oversight in the operating theatre. Attending surgeons responded utilising readily available technology for distance mentoring. Using this model, postgraduate surgical residents were able to complete 96% of trauma laparotomies safely without major complications.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres.

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery (MIS) because there are many factors that make laparoscopic pancreas resections difficult. The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries. However, this is not the environment that many surgeons in developing countries work in. These patients often do not have the opportunity to travel to high volume centres for care. Therefore, we sought to review the existing data on MIS for the pancreas and to discuss. In this paper, we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries, such as those in the Caribbean. This paper has two parts. First, we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas. The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice. Low pancreatic case volume in the Caribbean, and financial barriers to MIS in general, laparoscopic distal pancreatectomy, enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment. This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon's peri-operative experience.

Operating During the COVID-19 Pandemic: An Emerging Indication for Minilaparotomy Cholecystectomy.

COVID-19 has required changes in the practice of surgery to reduce the risk of transmission of the virus. Proposed mitigation strategies include avoidance of aerosol-generating procedures such as laparoscopy. We report two cases where minilaparotomy cholecystectomy was employed to treat benign biliary disease during the pandemic. A review of the literature supports the use of this surgical technique during the COVID-19 pandemic until laparoscopy can be proven to be safe.

Single Incision Laparoscopic Surgery: Feasibility of the Direct Fascial Puncture Technique Without Working Trocars.

Introduction As single-incision laparoscopic surgery (SILS) became popular, many access platforms and techniques emerged. When we initially described the direct fascial puncture (DFP) technique, many suggested it was not practical for three reasons: (1) increased hernia formation, (2) inability to complete operations without instrument changes and (3) insurmountable instrument drag. This study sought to determine whether the technique was a feasible approach by evaluating the outcomes with DFP-SILS in a single surgeon unit. Methods This was a retrospective audit of all consecutive patients who had unselected SILS operations by a single surgeon. For the DFP-SILS operation, a single optical trocar was used at the umbilicus, a second was rail-roaded beside the optical trocar and a third was directly passed across the fascia at the left-lateral extent of the skin wound. We recorded the number of conversions or failed operations and examined the patients routinely after operation to evaluate for incisional herniae. Results There were 50 DFP-SILS operations performed: 37 cholecystectomies, 12 appendectomies and one jejunal resection. The operations were successful in all cases with no conversions or mortality recorded. One patient (2%) developed a superficial surgical site infection after SILS-DFP appendectomy. The therapeutic outcomes were comparable to existing series of multi-port laparoscopy. There were no incisional herniae detected. Conclusion Even in the resource-poor setting, SILS operations are feasible and safe using the DFP technique. The theoretic concerns have not been realized in clinical practice.

Inferior Hepatic Fissures: Anatomic Variants in Trinidad and Tobago.

Classic descriptions of the visceral surface of the human liver only define three fissures: transverse, sagittal and umbilical fissures. Any additional fissures that are present on the visceral surface of the liver are considered variant inferior hepatic fissures (IHFs). This study was carried out to document the prevalence of IHFs in the Eastern Caribbean. Knowledge of these variants is important to clinicians who treat liver disorders in persons of the Caribbean diaspora. In this study, two independent researchers observed all consecutive autopsies performed at the facility over a period of 10 weeks. They examined the visceral surface of the unfixed liver in situ. Any specimen with variant IHFs was selected for detailed study. We documented the relation of the variant IHFs to nearby viscera and then explanted the livers using a standardized technique. The following details were recorded for each liver: number, location, depth, length, and width of IHFs. All measurements were checked independently by two researchers and the average measurement was used as the final dimension. Each liver was then sectioned in 1 cm sagittal slices to document the relationship of intraparenchymal structures. We observed 60 consecutive autopsies in unselected cadavers. Variant IHFs were present in 21 (35%) cadavers at a mean age of 68.25 years (range: 61 - 83; median 64.5; standard deviation (SD) ± 8.45). The variants included a deep fissure in the coronal plane between segments V and VI in 19 (31.7%) cadavers (related to the right branch of the portal vein in 63.2% of cases), a well-defined segment VI fissure running in a sagittal plane in four (6.7%) cadavers, a well-defined fissure incompletely separating the caudate process from the caudate lobe proper in five (8.3%) cadavers, a consistent fissure that arose from the left side of the transverse fissure and coursed between segments II and III in three (5%) cadavers, and a deep coronal fissure dividing the quadrate to form an accessory quadrate lobe in one (1.7%) cadaver. Almost one in three unselected persons in this population have anatomically variant fissures on the visceral surface of the liver. The variants include Rouvière's sulci (31.7%), caudate notches (8.3%), segment VI fissures (6.7%), left medial segment fissures (5%), and quadrate fissures (1.7%). The clinical relevance of these variants is discussed. Any clinician treating liver diseases in persons of Caribbean extract should be aware of their presence.

Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean.

BACKGROUND: Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease. There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes. These high volume referral centers are usually located in developed countries, but many patients in developing nations are not able to access these centers because of financial limitations, lack of social support and/or travel restrictions. Therefore, local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease. This is the situation in many Caribbean countries. AIM: To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the Caribbean. METHODS: We prospectively studied all patients who underwent major liver resections over five years. The following data were extracted: patient demographics, diagnoses, ECOG status, operation performed, post-operative morbidity and mortality. Statistical analyses were performed using SPSS ver 16.0. RESULTS: There were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/year. Sixty-nine major hepatic resections were performed for: colorectal liver metastases 40 (58%), non-colorectal metastases 9 (13%), hepatocellular carcinoma 8 (11.6%), ruptured adenomas 4 (5.8%), hilar cholangiocarcinomas 4 (5.8%), hemangiomata 2 (2.9%), trauma 1 (1.5%) and hepatoblastoma 1 (1.5%). Twenty-one patients had at least one complication, for an overall morbidity rate of 30.4%. There were minor complications in 17 (24.6%) patients, major complications in 11 (15.9%) patients and 4 (5.8%) deaths. CONCLUSION: There are unique geographic, political and financial limitations to healthcare delivery in the Caribbean. Nevertheless, clinical outcomes are acceptable in the established, low-volume hepatobiliary centers in the Eastern Caribbean.

Income Relates to Adherence in Youth with Type 1 Diabetes Through Parenting Constructs.

OBJECTIVE: Informed by the family stress and family investment models, this study investigated whether income is indirectly related to adherence and glycemic control through parenting constructs among youth with type 1 diabetes (TID). METHODS: Youth and their families (n = 390) from 4 geographically dispersed pediatric endocrinology clinics in the United States were participants in a multisite clinical trial from 2006 to 2009 examining the efficacy of a clinic-integrated behavioral intervention targeting family disease management for youth with TID. Baseline data were collected from youth aged 9 to 14 years and their parents. Parents reported family income and completed a semistructured interview assessing diabetes management adherence. Parents and children reported diabetes-specific parent-child conflict. Children completed measures of collaborative parent involvement and authoritative parenting. Hemoglobin A1c (HbA1c), a biomarker of glycemic control, was analyzed centrally at a reference laboratory. The relations of income, parenting variables, regimen, adherence, and HbA1c were examined using structural equation modeling. RESULTS: Lower family income was associated with greater parent-child conflict and a less authoritative parenting style. Authoritative parenting was associated with more collaborative parent involvement and less parent-child conflict, both of which were associated with greater adherence, which was associated with more optimal glycemic control (p < 0.05 all associations). Indirect effects of family income on adherence and glycemic control through parenting constructs were significant (p < 0.001). CONCLUSION: Findings lend support for the family stress and family investment models, suggesting that lower family income may negatively impact parent-child constructs, with adverse effects on diabetes management.

Modified hanging manoeuvre facilitates inferior vena cava resection and reconstruction during extended right hepatectomy: A technical case report.

Liver resections are safe when performed by specialized hepatobiliary teams. However, complex liver resections are accompanied by significant perioperative risk and they may require modifications of the conventional surgical techniques. We herein report the case of a 54-year-old male patient who underwent an extended right liver resection with en bloc resection and reconstruction of the inferior vena cava. For this complex resection, a modification of the standard operative technique was required. A modified hanging manoeuvre was performed using two 19Fr nasogastric tubes outside the traditional avascular plane to facilitate resection. This modification of the hanging manoeuvre was proven to be feasible and safe, and it is recommended for inclusion in the armamentarium of hepatobiliary surgeons when complex resections are required.

The acute effects of integrated myofascial techniques on lumbar paraspinal blood flow compared with kinesio-taping: A pilot study.

BACKGROUND: Myofascial techniques and Kinesio Taping are therapeutic interventions used to treat low back pain. However, limited research has been conducted into the underlying physiological effects of these types of treatments. OBJECTIVES: The purpose of this study was to compare the acute effects of integrated myofascial techniques (IMT) and Kinesio Tape (KT) on blood flow at the lumbar paraspinal musculature. METHODS: Forty-four healthy participants (18 male and 26 female) (age, 26 ± SD 7) volunteered for this study and were randomly assigned to one of three interventions, IMT, KT or a control group (Sham TENS). Paraspinal blood flow was measured at the L3 vertebral level, using Near Infrared Spectroscopy (NIRS), before and after a 30-min treatment. Pain Pressure Threshold (PPT) was also measured before and after treatments. RESULTS: A one-way ANOVA indicated a significant difference between groups for O2Hb [F (2-41) = 41.6, P < 0.001], HHb [F (2-41) = 14.6, P < 0.001] and tHb [F (2-41) = 42.2, P < 0.001]. Post hoc tests indicated that IMT was significantly greater, from the KT and the control treatments (P < 0.001), for changes in O2Hb, HHb, and tHb. There were no significant differences for PPT [F (2-41) = 2.69, p = 0.08], between groups. CONCLUSIONS: This study demonstrated that IMT increases peripheral blood flow at the paraspinal muscles in healthy participants compared to KT and sham TENS. The change in blood flow had no impact on pain perception in the asymptomatic population group.

A Management Algorithm for Retained Rectal Foreign Bodies.

Few authors have proposed therapeutic protocols to manage retained rectal foreign bodies (RFBs). All patients with retained RFBs in hospitals across Trinidad and Tobago over 5 years were identified. Hospital records were retrieved and manually reviewed to extract the following data: demographics, history, foreign body retrieved, clinical signs at presentation, management strategy, duration of hospitalization, and morbidity and mortality. There were 10 patients with RFBs over the study period. The annual incidence of this phenomenon was 0.15 per 100,000 population. All patients were men at a mean age of 50.6 years (range: 27-83; SD = 15.3) who presented after a voluntary delay of 1.4 days (range: 0.5-2.5; SD = 0.7). Only one patient gave an accurate history on presentation, but all eventually admitted to self-insertion for sexual gratification. At presentation, one patient had a spontaneous rectal perforation (10%). The remaining nine patients had attempts at bedside transanal extraction, which was unsuccessful in 89% (8/9) of cases. The RFB was pushed beyond the grasp of forceps, making removal under anesthesia unsuccessful in 62.5% (5/8) cases. These patients required more invasive extraction methods including transanal minimally invasive surgery (1), laparoscopic-assisted advancement with transanal retrieval (1), and open surgery with transmural extraction and anastomoses (3). A management algorithm is proposed for the management of RFBs. Important points in this algorithm are the importance of clinician-patient rapport, early surgical referral, avoidance of bedside extraction in the emergency room, early examination under anesthesia, and the inclusion of emerging therapies such as transanal minimally invasive surgery.

The hanging manoeuver to complete liver resection for a locally advanced angiosarcoma: A case report.

INTRODUCTION: Angiosarcomas arising in the liver are rare tumours in the Western world. We report a case of a locally advanced primary hepatic angiosarcoma and also describe the manoeuvres used to achieve operative resection. PRESENTATION OF A CASE: A 52-year old woman presented with vague right upper quadrant pain. Abdominal imaging revealed a heterogenous tumour in the right liver measuring 15centimetres in maximal diameter. Although the tumour was deemed to be resectable, there was free fluid in the right paracolic gutter suggestive of rupture. Intra-operatively, the peritoneal cavity was noted to be free of metastatic disease. However, tumour was adherent to the diaphragm precluding traditional mobilization of the liver. Therefore, a modified hanging manoeuvre was performed using a nasogastric tube. This allowed controlled mobilization of the right liver, parenchymal transection and en-bloc resection of the diaphragm with good hemostasis. Histologic examination revealed a primary angiosarcoma with uninvolved margins. DISCUSSION: When they occur, primary hepatic angiosarcomas are most often locally advanced. Nevertheless, surgeons should be aggressive in the pursuit of complete resections because this is the only therapeutic modality that has been shown to have a survival advantage. CONCLUSION: Hepatobiliary surgeons should keep the hanging manoeuver in their armamentarium when performing complex liver resections for locally advanced angiosarcomas.

Efficacy of a Behavioral Intervention for Pediatric Type 1 Diabetes Across Income.

INTRODUCTION: Youth with Type 1 diabetes and lower family income typically have poorer glycemic control. This post hoc analysis examines whether a family-oriented behavioral intervention for this population is differentially effective across income levels. METHODS: Families of youth aged 9-15 years with Type 1 diabetes (N=390; 49.2% female; age, 12.4 [1.7] years; hemoglobin A1c [HbA1c], 8.4 [1.2]; pump, 33.8%) at four U.S. pediatric endocrinology clinics participated in a 2-year RCT (data collected 2006-2011) of a clinic-integrated behavioral intervention designed to improve diabetes management by facilitating problem-solving skills, communication skills, and responsibility sharing. HbA1c was analyzed centrally. Family income was categorized as <$50,000 (low); $50,000 to <$100,000 (middle); and ≥$100,000 (high). Treatment effect was defined as the change in HbA1c from baseline to 2-year follow-up. A linear model tested the interaction of treatment effect with family income, controlling for race, insulin regimen, and site (analyzed in 2014). RESULTS: Baseline HbA1c was significantly poorer (p=0.004) in the low-income group. There was a significant overall effect of treatment group on change in HbA1c from baseline to follow-up (p=0.04). The interaction term for treatment by income group was not significant (p=0.44). Within each income category, a smaller deterioration in glycemic control was observed for the treatment group relative to controls. CONCLUSIONS: This clinic-integrated behavioral intervention was similarly effective in improving glycemic control among youth with Type 1 diabetes across income levels. This family-oriented problem-solving approach offers flexibility in addressing families' needs and may optimize impact on health outcomes across income groups.

Complex liver resections for colorectal metastases: are they safe in the low-volume, resource-poor Caribbean setting?

Introduction. Although many authorities suggest that major liver resections should only be carried out in high-volume specialized centres, many patients in the Caribbean do not have access to these health care systems. Presentation of a Case. A 50-year-old woman with a solitary colorectal metastasis invading the inferior vena cava underwent an extended left hepatectomy with caval resection and reconstruction. Several technical maneuvers were utilized that were suited to the resource-poor environment. Conclusion. We suggest that good outcomes can still be attained in the resource-poor, low-volume centres once dedicated and appropriately trained teams are available.

Evolution of SILS Cholecystectomy in the Caribbean: The Direct Transfascial Puncture Technique Using Conventional Instruments without Working Ports.

Introduction. Single incision laparoscopic cholecystectomy (SILC) has become accepted as an alternative to conventional multiport cholecystectomy. However, SILC is still limited in applicability in low resource centres due to the expense associated with specialized access platforms, curved instruments, and flexible scopes. Presentation of Case. We present three cases where a modified SILC technique was used with conventional instruments and no working ports. The evolution of this technique is described. Discussion. In order to contain cost, we used conventional instruments and three transfascial ports placed in an umbilical incision, but we noted significant instrument clashes that originated at the port platforms. Therefore, we modified our technique by omitting ports for the working instruments. The technique allowed us to exchange instruments as necessary, maximized ergonomics, and prevented collisions from the bulky port platforms. Finally, the puncture left by the instrument alone did not require fascial closure at the termination of the procedure. Conclusion. The direct transfascial puncture using conventional laparoscopic instruments without working ports is a feasible option that minimizes cost and increases ergonomics.