Rescue from complications after pancreaticoduodenectomies at a low-volume Caribbean center: Value of tailored peri-pancreatectomy protocols.

BACKGROUND: Pancreaticoduodenectomy (PD) is a technically complex operation, with a relatively high risk for complications. The ability to rescue patients from post-PD complications is as a recognized quality measure. Tailored protocols were instituted at our low volume facility in the year 2013. AIM: To document the rate of rescue from post-PD complications with tailored protocols in place as a measure of quality. METHODS: A retrospective audit was performed to collect data from patients who experienced major post-PD complications at a low volume pancreatic surgery unit in Trinidad and Tobago between January 1, 2013 and June 30, 2023. Standardized definitions from the International Study Group of Pancreatic Surgery were used to define post-PD complications, and the modified Clavien-Dindo classification was used to classify post-PD complications. RESULTS: Over the study period, 113 patients at a mean age of 57.5 years (standard deviation [SD] ± 9.23; range: 30-90; median: 56) underwent PDs at this facility. Major complications were recorded in 33 (29.2%) patients at a mean age of 53.8 years (SD: ± 7.9). Twenty-nine (87.9%) patients who experienced major morbidity were salvaged after aggressive treatment of their complication. Four (3.5%) died from bleeding pseudoaneurysm (1), septic shock secondary to a bile leak (1), anastomotic leak (1), and myocardial infarction (1). There was a significantly greater salvage rate in patients with American Society of Anesthesiologists scores ≤ 2 (93.3% vs 25%; P = 0.0024). 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 PD. Despite low volumes at our facility, we demonstrated that 87.9% of patients were rescued from major complications. We attributed this to several factors including development of rescue protocols, the competence of the pancreatic surgery teams and continuous, and adaptive learning by the entire institution, culminating in the development of tailored peri-pancreatectomy protocols.

Colorectal resections for malignancy: A pilot study comparing conventional vs freehand robot-assisted laparoscopic colectomy.

BACKGROUND: Laparoscopic colectomy is widely accepted as a safe operation for colorectal cancer, but we have experienced resistance to the introduction of the FreeHand® robotic camera holder to augment laparoscopic colorectal surgery. AIM: To compare the initial results between conventional and FreeHand® robot-assisted laparoscopic colectomy in Trinidad and Tobago. METHODS: This was a prospective study of outcomes from all laparoscopic colectomies performed for colorectal carcinoma from November 29, 2021 to May 30, 2022. The following data were recorded: Operating time, conversions, estimated blood loss, hospitalization, morbidity, surgical resection margins and number of nodes harvested. All data were entered into an excel database and the data were analyzed using SPSS ver 20.0. RESULTS: There were 23 patients undergoing colectomies for malignant disease: 8 (35%) FreeHand®-assisted and 15 (65%) conventional laparoscopic colectomies. There were no conversions. Operating time was significantly lower in patients undergoing robot-assisted laparoscopic colectomy (95.13 ± 9.22 vs 105.67 ± 11.48 min; P = 0.045). Otherwise, there was no difference in estimated blood loss, nodal harvest, hospitalization, morbidity or mortality. CONCLUSION: The FreeHand® robot for colectomies is safe, provides some advantages over conventional laparoscopy and does not compromise oncologic standards in the resource-poor Caribbean setting.

Aggressive Resection for a Primary Leiomyosarcoma of the Vena Cava Masquerading as a Pancreatic Head Tumor.

Smooth muscle is a normal component of the inferior vena cava (IVC) wall. Although uncommon, the smooth muscle component may undergo neoplastic change. Benign neoplasms are termed leiomyomas, and when there is a malignant change, the nomenclature is changed to an IVC leiomyosarcoma. Leiomyosarcomas of the IVC are rare, with less than 150 cases reported in medical literature. Unfortunately, the majority of IVC leiomyosarcomas are diagnosed at advanced disease stages. Surgical resection of locally advanced lesions is technically challenging, but complete resection is the mainstay of treatment as leiomyosarcomas respond poorly to chemo-radiotherapy. Due to the advanced disease stage at diagnosis and the technical complexity of IVC resection and reconstruction, most patients are transferred to high-volume centers in developed nations. We report a case of a patient with a locally advanced leiomyosarcoma masquerading as a pancreatic head tumor. This patient could not access care in a high-volume center and required aggressive maneuvers to resect the IVC leiomyosarcoma in a resource-poor, low-volume center. We present this case to highlight the steps in operative management and also to show that these procedures can be carried out in resource-poor environments once there is meticulous planning, appropriate equipment, and multidisciplinary care.

Multicenter Study of Laparoscopic Common Bile Duct Exploration for Choledocholithiasis in the English-Speaking Caribbean.

Background Common bile duct (CBD) exploration to address choledocholithiasis is not widely practiced in the English-speaking Caribbean. This study sought to determine the frequency of laparoscopic CBD explorations in the English-speaking Caribbean and to document the stone clearance rates and short-term outcomes of this procedure. Methods We accessed records for all practicing laparoscopic surgeons in the English-speaking Caribbean who performed laparoscopic CBD explorations over a 10-year period from January 1, 2013, to June 30, 2023. The following data were extracted retrospectively from patient records: demographic details, operating time, stone clearance rates, retained stone rates, conversions, and complications. All data were analyzed with SPSS version 20 (IBM Corp., Armonk, NY). Results Over the 10-year study period, 35 patients underwent laparoscopic cholecystectomy and synchronous CBD exploration in Barbados, Cayman Islands, Guyana, Grenada, St Lucia, and Trinidad & Tobago. The procedure was performed at low volumes of only 0.7 procedures per surgical team per annum. The conversion rate to open CBD exploration was 13% and when laparoscopic CBD exploration was completed, it resulted in 96.3% stone clearance, 3.7% retained stones, mean hospitalization of two days, 9.7% minor morbidity, and no mortality. Conclusion Laparoscopic CBD exploration is feasible in the resource-poor Caribbean setting, and it yields good results, with 96.3% stone clearance rates, 9.7% minor morbidity, and no mortality. These results are better than those reported in Caribbean literature for stone extraction with endoscopic retrograde cholangiopancreaticography (ERCP).

Preoperative echocardiography for patients with hip fractures undergoing surgery in a low-resource setting: Asset or obstacle?

The aim of this study was to determine the rate of preoperative transthoracic echocardiography in hip fracture patients and to evaluate its effects on time to surgery and length of stay. We conducted a retrospective review of all patients with hip fractures treated at a tertiary referral hospital. Data examined included age, sex, comorbidities, time to surgery, length of stay, fracture type and transthoracic echocardiography findings. Forty-eight patients with hip fractures underwent surgery (men 41.7%; mean age 77.2 (49-95)). Nine patients (18.7%) had a preoperative transthoracic echocardiography. Preoperative transthoracic echocardiography was associated with a significantly longer time to surgery an abbreviation for days e.g dys should be added after the values to indicate what time frame is being measured (14.7 versus 6.8, p = 0.0051) and length of stay (23.6 versus 10.4, p = 0.0002). This study demonstrates a high rate of preoperative transthoracic echocardiography in hip fracture patients. The role of transthoracic echocardiography should be reassessed in view of its association with significant surgical delays.

Robot-Assisted Common Bile Duct Exploration in Trinidad & Tobago.

Although laparoscopic common bile duct exploration is a feasible and safe option for the operative management of choledocholithiasis, there has been a general reluctance to perform this procedure in Caribbean practice. This is largely because duct exploration is perceived to be difficult with laparoscopic instruments, and endoscopic retrograde cholangiopancreatography (ERCP) has become increasingly available. We report a case in which stones were extracted laparoscopically from the common bile duct, aided by the FreeHand® (Freehand 2010 Ltd., Guildford, Surrey, UK) robot, to show that the procedure is feasible and safe in the Caribbean environment.

A Comparison of the Celiacomesenteric Trunk in the Caribbean with Global Prevalence Calculated by a Systematic Review.

Background: Typically, the celiac trunk and superior mesenteric artery branch off separately from the anterior aspect of the abdominal aorta. The celiacomesenteric trunk (CMT) is a rare variant in which those arteries share a common origin. We sought to compare the prevalence of CMT in the Caribbean with the global prevalence as calculated by a systematic review. Methods: In this study, we evaluated all consecutive patients who had multiphase contrast-enhanced CT scans at two major referral centres in the Caribbean from August 30, 2017, to September 1, 2019. In patients with a CMT, we recorded demographic and anatomic details. We then conducted a systematic literature search and retrieved raw data to calculate the global prevalence (number of individuals with a CMT divided by the sum total of study samples). We compared CMT prevalence in our sample with the global prevalence using Pearson's chi-square and Fisher's exact tests. Statistical significance was considered to be present when the P value was <0.05. Results: From 832 CTs, 665 scans met the inclusion criteria. There were 16 (2.41%) CMTs: 3 (0.45%) classic CMTs, 12 (1.8%) hepato-mesenteric trunks, and 1 (0.15%) hepato-spleno-mesenteric trunk. Forty-two studies reported on CMTs in a total of 74,320 persons. The global CMT prevalence was comparable (3.88%; P = 0.054), but the incidence of hepato-mesenteric variants was significantly lower in our sample (1.8% vs. 3.24%; P = 0.0352). Conclusion: There was no difference in the prevalence of a classic CMT in the Caribbean compared to the global prevalence. However, the hepato-mesenteric trunk (incomplete CMT variant) was significantly less prevalent in the Caribbean. Advances in Knowledge: Healthcare professionals performing hepatobiliary interventions must be aware of these differences in order to minimize morbidity during their interventions.

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.

Greater Gender Diversity Observed at Orthopaedic Conferences in the Caribbean Than in the United States or England.

Introduction Women are underrepresented in orthopaedics. Recent studies have shown that women comprise only a very small proportion of all practising orthopaedic surgeons in the United States. One theory that seeks to explain this disparity is the lack of female mentors in orthopaedic surgery. Women are particularly influenced by same-sex mentors, and the paucity of mentors sets up a negative feedback loop that further reduces applications to residency programs. Presentation of scholarly work at conferences increases the visibility of women and represents important opportunities to encourage young female doctors to the speciality. The annual meeting of The Caribbean Association of Orthopaedic Surgeons (TCOS) is a forum that allows regional exposure to young doctors. In the present work, we aim to analyse the gender diversity among presenters at the annual TCOS meetings. Methods A retrospective analysis of the final programs of TCOS meetings over five years was conducted to determine the sex of the presenter, their roles, and topics. The first author listed on the program was taken as the presenter unless it was otherwise stated. Gender was determined using conventional naming taxonomy. Presenters were classified as podium presenters or moderators and presentations as clinical or non-clinical. We subdivided clinical presentations into seven subspecialty areas. A Chi-squared test was used to calculate differences between groups, with a p-value of < 0.05 representing significance. Statistical tests were performed using Analyse-it for Microsoft Excel 5.40 (Analyse-it Software Ltd). Results There was a total of 195 podium presentations over the study period. During this time, there was a steady increase in the number of presentations by women, with a mean value of 19.5%. Compared with men, women presented fewer clinical papers (52.6%vs 73.9%, p=0.037), presented on more general topics (63.2% vs 31.2%, p=0.007) and were less likely to moderate a session (2.7% vs 97.3%, p=0.014). Presentations by female residents were marginally higher than the mean rate for women overall and were representative of the gender distribution in the resident pool. Conclusions There are significantly fewer presentations by women than men at the annual TCOS meetings. Encouragingly, however, there is a positive trend towards greater female presentations over the study period. Our results show that despite being underrepresented, more women are presenting at orthopaedic conferences in the Caribbean than in the United States or England.

Whipple's operation with a modified centralization concept: A model in low-volume Caribbean centers.

Conventional data suggest that complex operations, such as a pancreaticoduodenectomy (PD), should be limited to high volume centers. However, this is not practical in small, resource-poor countries in the Caribbean. In these settings, patients have no option but to have their PDs performed locally at low volumes, occasionally by general surgeons. In this paper, we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations. Specifically, we discuss a modification of this concept that may be considered when incorporating PD 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 studies published on outcomes after PD in high volume centers. The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept. In the authors' opinions, most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries. In these settings, their only options are to have their operations in the resource-poor, low-volume settings in the Caribbean. However, post-operative outcomes may be improved, despite low-volumes, if a modified centralization concept is encouraged.

Laparoscopic Release for Median Arcuate Ligament Compression Syndrome Associated with a Celiac-Mesenteric Trunk.

The median arcuate ligament compression syndrome is a rare entity that occurs in 2 per 100,000 unselected individuals. We present a case where the median arcuate ligament compression syndrome was associated with an equally uncommon anatomic variation-a celiac-mesenteric trunk, which occurs in 0.42-2.7% of unselected individuals. We could find no prior report of a celiac-mesenteric trunk being associated with the median arcuate ligament compression syndrome. This report also adds to the literature to show that a laparoscopic approach to median arcuate ligament release is feasible.

Colorectal cancer in an Eastern Caribbean nation: are we missing an opportunity for secondary prevention?

Objective: To establish whether there was any difference in disease stage in patients with screening-detected colorectal cancer (CRC) in a Caribbean country. Methods: The mode of presentation (elective vs. emergent), method of diagnosis (screening vs. symptomatic), and disease stage were retrospectively compared in all consecutive patients who had resections for CRC over a five-year period. Early CRC was defined as disease that could be completely resected with no involvement of adjacent organs, lymph nodes, or distant sites. Locally advanced CRC was disease that involved contiguous organs without distant metastases that was still amenable to curative resection. Results: There were 97 patients at a mean age of 64.9 ± 12.2 years treated for CRC, and only 21 (21.6%) had their diagnoses made through screening. Significantly more screening-detected lesions were early-stage CRCs (21.7% vs. 9.3%; p < 0.001). At the time of diagnosis, patients who did not have screening-detected lesions had a greater proportion of locally advanced (42.3% vs. 0) and metastatic (26.8% vs. 0) CRC. Those who did not have screening-detected lesions had a greater incidence of emergency presentations at diagnosis (26.8% vs. 0). Conclusions: The incidence of screening-detected CRC in this Caribbean nation was low. Consequently, most patients presented with locally advanced or metastatic CRC, for which there is less opportunity to achieve a cure. Significantly more screening-detected lesions were early-stage CRCs. It is time for policymakers to develop a national CRC screening program.

Colorectal cancer in an Eastern Caribbean nation: are we missing an opportunity for secondary prevention?

[ABSTRACT]. Objective. To establish whether there was any difference in disease stage in patients with screening-detected colorectal cancer (CRC) in a Caribbean country. Methods. The mode of presentation (elective vs. emergent), method of diagnosis (screening vs. symptomatic), and disease stage were retrospectively compared in all consecutive patients who had resections for CRC over a five-year period. Early CRC was defined as disease that could be completely resected with no involvement of adjacent organs, lymph nodes, or distant sites. Locally advanced CRC was disease that involved contiguous organs without distant metastases that was still amenable to curative resection. Results. There were 97 patients at a mean age of 64.9 ± 12.2 years treated for CRC, and only 21 (21.6%) had their diagnoses made through screening. Significantly more screening-detected lesions were early-stage CRCs (21.7% vs. 9.3%; p < 0.001). At the time of diagnosis, patients who did not have screening-detected lesions had a greater proportion of locally advanced (42.3% vs. 0) and metastatic (26.8% vs. 0) CRC. Those who did not have screening-detected lesions had a greater incidence of emergency presentations at diagnosis (26.8% vs. 0). Conclusions. The incidence of screening-detected CRC in this Caribbean nation was low. Consequently, most patients presented with locally advanced or metastatic CRC, for which there is less opportunity to achieve a cure. Significantly more screening-detected lesions were early-stage CRCs. It is time for policymakers to develop a national CRC screening program.

[RESUMEN]. Objetivo. Determinar las diferencias en el estadio de la enfermedad en pacientes con cáncer colorrectal diagnosticado mediante un programa de detección sistemática en un país del Caribe. Métodos. Se realizó una comparación en retrospectiva de la modalidad de presentación (programada o de urgencia), el método de diagnóstico (por detección sistemática o por síntomas) y el estadio de la enfermedad en todos los pacientes consecutivos con resecciones por cáncer colorrectal en un período de cinco años. Se definió el cáncer colorrectal en fase inicial o incipiente como una enfermedad que puede extirparse completamente sin la afectación de los órganos adyacentes, los ganglios linfáticos o focos distantes. Se consideró el cáncer colorrectal localmente avanzado como una enfermedad que afecta a los órganos contiguos sin metástasis a distancia y aún susceptible de resección curativa. Resultados. Hubo 97 pacientes de una media de edad de 64,9 ± 12,2 años en tratamiento por cáncer colorrectal y únicamente 21 (21,6%) habían recibido un diagnóstico mediante un programa de detección sistemática. Un número significativamente mayor de los diagnósticos dados por detección sistemática se trató de cáncer colorrectal de fase inicial (21,7 % frente a 9,3 %; p < 0,001). En el momento del diagnóstico, se registró una mayor proporción de cáncer colorrectal localmente avanzado (42,3 % frente a 0) y metastásico (26,8 % frente a 0) en los pacientes sin lesiones diagnosticadas en un programa de detección sistemática. Los pacientes cuyas lesiones no fueron diagnosticadas mediante la detección sistemática registraron una mayor incidencia de presentaciones de urgencia en el momento del diagnóstico (26,8 % frente a 0). Conclusiones. La incidencia de cáncer colorrectal diagnosticado mediante detección sistemática en este país del Caribe fue baja. En consecuencia, la mayoría de los pacientes presentó cáncer colorrectal localmente avanzado o metastásico, cuya oportunidad de cura es menor. Un número significativamente mayor de lesiones diagnosticadas mediante detección sistemática se trató de cáncer colorrectal de fase inicial. Ha llegado el momento de que las personas responsables de las políticas elaboren un programa nacional de detección sistemática de cáncer colorrectal.

[RESUMO]. Objetivo. Determinar se houve diferença no estágio da doença detectada no exame de prevenção de câncer colorretal em um país do Caribe. Métodos. Fatores como tipo de apresentação (eletiva vs. de emergência), método de diagnóstico (prevenção vs. detecção sintomática) e estágio da doença foram comparados retrospectivamente em todos os pacientes consecutivos submetidos a cirurgia de ressecção de câncer colorretal em um período de cinco anos. Definiu-se doença em estágio inicial como o tumor passível de ressecção total sem o envolvimento de órgãos adjacentes, gânglios linfáticos ou sítios a distância, e doença localmente avançada como o tumor envolvendo órgãos contíguos, sem metástase a distância, mas passível de resseção curativa. Resultados. Noventa e sete pacientes com média de idade de 64,9 ± 12,2 anos foram tratados devido ao câncer colorretal e apenas 21 (21,6%) tiveram a doença diagnosticada no exame de prevenção. Um percentual significativamente maior de lesões detectadas no exame de prevenção estava em estágio inicial (21,7% vs. 9,3%; p < 0.001). No momento do diagnóstico, os pacientes cujas lesões de câncer colorretal não foram detectadas com o exame de prevenção apresentaram um maior percentual de doença localmente avançada (42,3% vs. 0) ou metastática (26,8% vs. 0). Houve também, entre esses pacientes, uma maior incidência de apresentação em caráter de emergência (26,8% vs. 0). Conclusões. Observou-se uma baixa incidência de câncer colorretal na população deste país do Caribe. Porém, a maioria dos pacientes apresentou doença localmente avançada ou metastática no diagnóstico – uma situação associada a uma menor chance de cura. O percentual de lesões detectadas em estágio inicial com o exame de prevenção foi significativamente maior. As autoridades de saúde devem aproveitar a oportunidade e instituir um programa nacional de prevenção do câncer colorretal.

Single Incision Cholecystectomies for Acute Cholecystitis: A Single Surgeon Series from the Caribbean.

INTRODUCTION: Single incision laparoscopic surgery (SILS) is accepted as a safe alternative to conventional multiport laparoscopic (MPL) cholecystectomy for benign gallbladder disease. Since many surgeons carefully select patients without inflammation, there are limited data on SILS for acute cholecystitis. We report a single surgeon experience with SILS cholecystectomy for patients with acute cholecystitis. MATERIALS AND METHODS: After securing ethical approval, we performed an audit of all SILS cholecystectomies for acute cholecystitis by a single surgeon from January 1, 2009, to December 31, 2019. The following data were extracted: patient demographics, intraoperative details, surgical techniques, specialized equipment utilized, conversions (additional port placement), morbidity, and mortality. Data were analyzed using SPSS 12.0. RESULTS: SILS cholecystectomy was performed in 25 females at a mean age of 35 ± 4.1 (SD) years and a mean BMI of 31.9 ± 3.8 (SD) using a direct fascial puncture technique without access platforms. The operations were completed in 83 ± 29.4 minutes (mean ± SD) with an estimated blood loss of 76.9 ± 105 (mean + SD). Three (12%) patients required additional 5 mm port placement (conversions), but no open operations were performed. The patients were hospitalized for 1.96 ± 0.9 days (mean ± SD). There were 2 complications: postoperative superficial SSI (grade I) and a diaphragmatic laceration (grade III). No bile duct injuries were reported. There were 9 patients with complicated acute cholecystitis, and this sub-group had longer mean operating times (109.2 ± 27.3 minutes) and mean postoperative hospital stay (1.3 ± 0.87 days). CONCLUSION: The SILS technique is a feasible and safe approach to perform cholecystectomy for acute cholecystitis. We advocate a low threshold to place additional ports to assist with difficult dissections for patient safety.

Emergency single-incision laparoscopic cholecystectomy for acute cholecystitis: A multi-center study.

Single-incision laparoscopy is accepted as a safe alternative to multiple port laparoscopy for elective cholecystectomy; however, there are limited data on its use in patients with acute cholecystitis. The present multi-center study evaluated the outcomes of emergency single-incision surgeries for acute cholecystitis in hospitals in Belgium, Jamaica, and Trinidad and Tobago over a 5-year period. Standardized definitions of uncomplicated and complicated acute cholecystitis were used and the data were compared using SPSS software. The results revealed that over the 5-year period, 108 patients with a mean age of 48±15 years and a mean body mass index of 27±4.2 kg/m2 underwent emergency single-incision cholecystectomies. The surgeries were successful in 92.1% of cases without supplemental trocars being used. The overall morbidity rates (9.3%) were also comparable to the historic controls with multiple port cholecystectomy. As was expected, the complicated cholecystitis group required a significantly longer operating time (86.11±30.16 vs. 66.79±16.8; P<0.00194), as well as supplemental trocars (7.9%) vs. 0; P=0.0413). On the whole, the present study demonstrates that emergency single-incision cholecystectomy is a technically feasible and safe procedure for patients with acute cholecystitis. These findings advocate a low threshold to place additional ports to assist with dissection and exposure.

Clinical yield of screening colonoscopies in Jamaica.

There is still no organised national screening programme for colorectal cancer in Jamaica. We sought to evaluate the detection of colorectal cancer precursor lesions in patients who underwent opportunistic screening over three years. Patients with colorectal polyps were selected for further study. In 431 procedures, there were 84 (19.5%) patients with colorectal polyps identified at screening colonoscopy, which gave a 19.5% sensitivity to identify patients with polyps at risk of developing colorectal cancer, 9.5% being <50 years of age. At the time of examination, 16.7% had already developed invasive adenocarcinoma. We conclude that it is time for policy makers to develop a national colorectal cancer screening programme to diagnose patients early and improve their therapeutic outcomes.

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.

Colorectal cancer in an Eastern Caribbean nation: are we missing an opportunity for secondary prevention? / El cáncer colorrectal en un país del Caribe oriental: ¿estamos desaprovechando una oportunidad de prevención secundaria? / Câncer colorretal em um país do Caribe Oriental: estamos deixando passar a oportunidade de realizar a prevenção secundária?

ABSTRACT Objective. To establish whether there was any difference in disease stage in patients with screening-detected colorectal cancer (CRC) in a Caribbean country. Methods. The mode of presentation (elective vs. emergent), method of diagnosis (screening vs. symptomatic), and disease stage were retrospectively compared in all consecutive patients who had resections for CRC over a five-year period. Early CRC was defined as disease that could be completely resected with no involvement of adjacent organs, lymph nodes, or distant sites. Locally advanced CRC was disease that involved contiguous organs without distant metastases that was still amenable to curative resection. Results. There were 97 patients at a mean age of 64.9 ± 12.2 years treated for CRC, and only 21 (21.6%) had their diagnoses made through screening. Significantly more screening-detected lesions were early-stage CRCs (21.7% vs. 9.3%; p < 0.001). At the time of diagnosis, patients who did not have screening-detected lesions had a greater proportion of locally advanced (42.3% vs. 0) and metastatic (26.8% vs. 0) CRC. Those who did not have screening-detected lesions had a greater incidence of emergency presentations at diagnosis (26.8% vs. 0). Conclusions. The incidence of screening-detected CRC in this Caribbean nation was low. Consequently, most patients presented with locally advanced or metastatic CRC, for which there is less opportunity to achieve a cure. Significantly more screening-detected lesions were early-stage CRCs. It is time for policymakers to develop a national CRC screening program.

RESUMEN Objetivo. Determinar las diferencias en el estadio de la enfermedad en pacientes con cáncer colorrectal diagnosticado mediante un programa de detección sistemática en un país del Caribe. Métodos. Se realizó una comparación en retrospectiva de la modalidad de presentación (programada o de urgencia), el método de diagnóstico (por detección sistemática o por síntomas) y el estadio de la enfermedad en todos los pacientes consecutivos con resecciones por cáncer colorrectal en un período de cinco años. Se definió el cáncer colorrectal en fase inicial o incipiente como una enfermedad que puede extirparse completamente sin la afectación de los órganos adyacentes, los ganglios linfáticos o focos distantes. Se consideró el cáncer colorrectal localmente avanzado como una enfermedad que afecta a los órganos contiguos sin metástasis a distancia y aún susceptible de resección curativa. Resultados. Hubo 97 pacientes de una media de edad de 64,9 ± 12,2 años en tratamiento por cáncer colorrectal y únicamente 21 (21,6%) habían recibido un diagnóstico mediante un programa de detección sistemática. Un número significativamente mayor de los diagnósticos dados por detección sistemática se trató de cáncer colorrectal de fase inicial (21,7 % frente a 9,3 %; p < 0,001). En el momento del diagnóstico, se registró una mayor proporción de cáncer colorrectal localmente avanzado (42,3 % frente a 0) y metastásico (26,8 % frente a 0) en los pacientes sin lesiones diagnosticadas en un programa de detección sistemática. Los pacientes cuyas lesiones no fueron diagnosticadas mediante la detección sistemática registraron una mayor incidencia de presentaciones de urgencia en el momento del diagnóstico (26,8 % frente a 0). Conclusiones. La incidencia de cáncer colorrectal diagnosticado mediante detección sistemática en este país del Caribe fue baja. En consecuencia, la mayoría de los pacientes presentó cáncer colorrectal localmente avanzado o metastásico, cuya oportunidad de cura es menor. Un número significativamente mayor de lesiones diagnosticadas mediante detección sistemática se trató de cáncer colorrectal de fase inicial. Ha llegado el momento de que las personas responsables de las políticas elaboren un programa nacional de detección sistemática de cáncer colorrectal.

RESUMO Objetivo. Determinar se houve diferença no estágio da doença detectada no exame de prevenção de câncer colorretal em um país do Caribe. Métodos. Fatores como tipo de apresentação (eletiva vs. de emergência), método de diagnóstico (prevenção vs. detecção sintomática) e estágio da doença foram comparados retrospectivamente em todos os pacientes consecutivos submetidos a cirurgia de ressecção de câncer colorretal em um período de cinco anos. Definiu-se doença em estágio inicial como o tumor passível de ressecção total sem o envolvimento de órgãos adjacentes, gânglios linfáticos ou sítios a distância, e doença localmente avançada como o tumor envolvendo órgãos contíguos, sem metástase a distância, mas passível de resseção curativa. Resultados. Noventa e sete pacientes com média de idade de 64,9 ± 12,2 anos foram tratados devido ao câncer colorretal e apenas 21 (21,6%) tiveram a doença diagnosticada no exame de prevenção. Um percentual significativamente maior de lesões detectadas no exame de prevenção estava em estágio inicial (21,7% vs. 9,3%; p < 0.001). No momento do diagnóstico, os pacientes cujas lesões de câncer colorretal não foram detectadas com o exame de prevenção apresentaram um maior percentual de doença localmente avançada (42,3% vs. 0) ou metastática (26,8% vs. 0). Houve também, entre esses pacientes, uma maior incidência de apresentação em caráter de emergência (26,8% vs. 0). Conclusões. Observou-se uma baixa incidência de câncer colorretal na população deste país do Caribe. Porém, a maioria dos pacientes apresentou doença localmente avançada ou metastática no diagnóstico - uma situação associada a uma menor chance de cura. O percentual de lesões detectadas em estágio inicial com o exame de prevenção foi significativamente maior. As autoridades de saúde devem aproveitar a oportunidade e instituir um programa nacional de prevenção do câncer colorretal.

Robot-Assisted Minimally Invasive Surgery: First Report from the Caribbean.

Although advanced minimally invasive surgery and robotic surgery were well accepted in developed countries by the turn of the 21st century, they did not enjoy the same popularity in the Anglophone Caribbean. Advanced minimally invasive surgery only became available in select Caribbean countries from the year 2010. And up to the year 2021, robotic surgery was completely non-existent in the Anglophone Caribbean. Surgical leaders in the Anglophone Caribbean recognized a need to encourage the introduction of advanced surgical techniques in the region and engaged local and international stakeholders in an attempt to stimulate this development. In the year 2021, through a collaborative effort by a local medical university, a government-funded hospital, and industry partners in the United Kingdom, robot-assisted minimally invasive surgery was successfully introduced to the Caribbean. We report our experience of introducing robot-assisted minimally invasive surgery in the Eastern Caribbean. By discussing the pitfalls and successes from our experience, we hope that the lessons can be used to guide the introduction of robot-assisted minimally invasive surgery in other resource-poor countries in the Caribbean.​.