Surgery for patent ductus arteriosus

The surgical treatment of Patent Ductus Arteriosus (PDA) at the University Hospital of the West Indies, Kingston, Jamaica was examined over an eight-year period. The results of standard surgical modalities were comparable to large published series. A review of the literature regarding the treatment options for PDA does not support a change in management strategy in favour of non-surgical methods. The treatment of PDA at this centre has shown excellent long-term results, with miminal mortality and morbidity.(Au)

Penetrating Injury to the great vessels: case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.

Penetrating Injury to the Great Vessels: Case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.(AU)

Granulosa-theca cell tumour of the ovaries. A late metastasizing tumour

Granulosa-theca cell tumours are ovarian neoplasms of low malignancy with hormone secreting potential, accounting for 2-3 percent of all ovarian cancers. They have an uncertain clinical course and a potential for late recurrence aftet surgical removal. Clincal features of a patient presenting with pulmonary metastases 21 years after removal of the primary tumour are described, along with a review of the management options.(AU)

Ectopia cordis: ethical dilemma in a developing country

Etopia cordis is a rare congenital abnormality affecting the heart which is present either totally or partially outside the thorax. Because of associated cardiac defects, survival beyond birth is uncommon. One such case in whom death occurred on the 23rd post-operative day from heart failure is described and the management and ethical considerations discussed. This is the first case which has survived beyond birth in Jamaica.

Ectopia cordis: ethical dilemma in a developing country

Etopia cordis is a rare congenital abnormality affecting the heart which is present either totally or partially outside the thorax. Because of associated cardiac defects, survival beyond birth is uncommon. One such case in whom death occurred on the 23rd post-operative day from heart failure is described and the management and ethical considerations discussed. This is the first case which has survived beyond birth in Jamaica. (AU)

Open-heart surgery in a developing country - Jamaica - abstract

Open-heart surgery, using the Heart Lung machine, was first performed on May 6, 1953. Fifteen years later, the first open-heart surgery operation was performed at the University of the West Indies. Since then, just under 700 cases have been done. There has been a varying number of cases performed each year, ranging from 53 cases in the best year to one in the worst year. Despite the long tradition, we still continue to get the sort of publicity in daily newspaper articles: "Young beautician needs heart surgery" which appeared during the week of June 14-10, 1993 and the most recent article "Open-heart surgery here soon" appearing in the Gleaner Publication of Sunday, July 11, 1993. Open-heart surgery, in a developing country such as Jamaica, is handicapped by late disease, inadequate investigation, lack of equipment and personnel shortage. At present, valve surgery is the main operation performed on the basis of clinical and echocardiographic findings. Congenital conditions are done, such as atrial septal defects and ventricular septal defects in older children. With the refurbishing of the catheterization laboratory to be completed shortly, the number of cases awaiting surgery will increase. We will be faced with a large patient population requiring surgery, with inadequate resources to meet the demand. Jamaica, like all developing countries, is faced with the dilemna of providing expensive but necessary surgery for its population (AU)

Thymectomy in myasthenia gravis: the Jamaican experience

Forty-five patients with myasthenia gravis (MG) were subjected to thymectomy by the median sternotomy technique and were followed up for 4,380 patient months. No operative deaths occurred and 93.3 percent of the patients benefited from surgery with 28.8 percent achieving remission. Forty patients (88.5 percent) showed improvement within one month, and 73 percent of those who achieved remission did so in the first 2 years. Outcome was not affected by thymic pathology except in one patient who had a thymoma removed. These results confirm the value of thymectomy in the management of MG patients with generalised disease and the efficacy of the simple median sternotomy procedure (AU)

Myasthenia gravis in Jamaica: clinical, immunological and genetic studies

Clinical, immunological and genetic parameters were studied in 73 Jamaican patients with myasthenia gravis (Mg). The reported biomodal clinical distribution of females with early onset of disease and males with late onset was not observed. The female to male ratio was 2:1. The most frequent manifestations of disease were ptosis (84.9 percent), general muscle weakness (68.5 percent), bulbar symptoms (41.1 percent) and diplopia (32.9 percent). Unusual presenting features such as unilateral ptosis, recurrent chest infection and stumbling while walking resulted in diagnosis being missed in 5.8 percent of cases. The sensitivity of radiommunoassay in detecting acetylcholine receptor antibody (AchR-Ab) in sera from a subgroup of 35 MG patients was 71.4 percent whilst that of the ELISA was only 14.2 percent. There was no correlation between HLA-type, thymic pathology and course of disease. HTLV-I could not be implicated in the pathogenesis of this disease. There was a paucity of other associated autoimmune conditions among MG patients. Thymectomy was an important therapeutic modality in that improvement was observered in 22 cases and remission in 11. (AU)

Caustic strictures of the oesophagus

Ingestion of caustic material is a major management problem which occurs most commonly in children. Twenty-five patients with caustic ingestion seen over a ten-year period are reported. Twelve patients had severe burns, resulting in oesophageal strictures. Of these, ten were children below six years of age (median age, 3 years). Dysphagia and vomitting were the main presenting features. Oropharyngeal burn was present in 83 percent of patients with oesophageal burns. The strictures involved the entire oesophagus in two patients, the upper third in four, the mid oesophagus in two and the lower third in four. Periodic dilatations were successful in restoring an adequate lumen in 7 patients with short strictures. Five patients required surgery. There was one death. Caustic damage to the oesophagus is preventable. Education of the public and simple measures by manufacturers of caustics are urgently needed (AU)

Endodermal sinus (yolk sac) tumour of the mediastinum

An endodermal sinus tumour of the anterior mediastinum is described in a 19-year-old man. This very rare condition is reported for the Caribbean literature (AU)

Leiomyoma of the trachea

A case of leiomyoma of the trachea is described. Only fourteen cases of this tumour have been previously reported in the literature. The importance of early diagnosis and treatment is discussed (AU)

Dysphagia lusoria: a rare cause of dysphagia

Dysphagia lusoria is a rare cause of dysphagia. It is usually due to a combination of an aberrant right subclavian artery and either a close origination of the common carotid trunk. A middle-aged man presenting with dysphagia due to an aberrant right subclavian artery and closely originating carotid arteries less than 1 cm apart is presented. Barium swallow demonstrated the characteristic oblique external compression effect on the upper posterior oesophagus. Oesphagoscopy confirmed an extrinsic defect in the upper oesophagus which was pulsatile. Dysphagia lusoria is a clinical entity that is not well recognized and should be considered in patients with upper oesphageal dysphagia in whom the cause is not obvious (AU)

Closed mitral valve commissurotomy in West Indian patients results of operative palliation (1955 to 1985)

A retrospective study of all patients subjected to closed mitral valve commissurotomy from 1955 to 1985 at the University Hospital revealed low morbidity and mortality rates associated with surgery. Out-patient follow-up studies indicate adequate symptomatic relief over a period of 1 to 27 years. Patients with isolated significant mitral stenosis should, therefore, be considered for surgical palliation (AU)

Idiopathic pulmonary artery dilation

Idiopathic pulmonary artery dilation is a rare but definite clinical entity. It must be distinguished from dilatation secondary to congenital and acquired cardiac or pulmonary disorders causing pulmonary hypertension. A middle-aged woman with idiopathic pulmonary artery dilation who was initally referred for evaluation of a mediastinal tumor is described. Idiopathic pulmonary artery dilatation should be considered in any patient with a prominent pulmonary arch and normal peripheral lung vascularity (AU)

Mitral stenosis in West Indian patients: results of closed mitral commissurotomy (1955-1985) at the University Hospital of the West Indies - abstract

Mitral stenosis (MS) is not infrequently seen in patients presenting at referral clinics in the University Hospital (UH). These patients are offered surgical palliation - Closed mitral commissurotomy (CMC) - as published reports indicate such therapy is quite satisfactory. A study of all patients subjected to CMC for MS at UH was undertaken to evaluate the results of this operation. There were 97 women and 23 men and their ages ranged from 9 to 57 years (mean 24.7). A clinical diagnosis of MS was made in all patients. Thirty-four and 28 patients were subjected to cardiac catheterisation and echocardiography respectively to confirm the clinical diagnosis and /or to exclude other cardio-vascular abnormalities. The operative procedures performed were as follows: CMC - 117, CMC + lung biopsy - 1, Thoracotomy - 1, Prosthetic aortic and mitral valve replacement (failed CMC) - 1, Total = 120; Subsequent operations performed were as follows:- CMC - 1, Homograft mitral valve replacement - 5, Porcine xenograft mitral valve replacement - 3, Tracheostomy - 1, Thoracotomy (tamponade2, no tamponade 2) - 4, Total = 14. There were 3 intra-operative deaths (left coronary embolus, bleeding, acute cardiac failure), a 2.5 per cent mortality. Five and 9 patients died in the early and late post-operative periods respectively (cardiac failure, systemic embolisation, re-stenosis, re-operative), 4.2 and 7.5 per cent mortality. Follow-up studies after CMC indicate adequate symptomatoic relief over a period of 1 to 27 years. The results of CMC at UH indicate that the techniques of anaesthesia and surgery are associated with low morbidity and mortality. Patients with MS should therefore be considered for surgical palliation (AU)

Left atrial myxoma: an unusual cause of acute pulmonary oedema

A case of left atrial myxoma presenting as acute pulmonary oedema is described. As far as we are aware, this is the report in the West Indian medical literature of accurate pre-operative diagnosis and successful surgical excision of such a tumour. Recent improvements in the accuracy of pre-operative diagnosis are discussed, and the present day availability of surgical excision, utilising cardio-pulmonary bypass with excellent post-operative results at low-risk, make response of this case of considerable importance. (AU)

Patent ductus arteriosus: result of operative intervention (1953-1984)

A retrospective study of all patients with patent ductus arteriosus treated surgically from 1953 to 1984 at the University and National Chest Hospitals revealed low morbidity and mortality rates associated with anaesthesia and surgical treatment. Patients with patent ductus arteriosus should, therefore, be considered for surgical correction. (AU)

Patent ductus arteriosus in West Indian children - abstract

Patent ductus arteriosus (PDA) is frequently seen in children presenting at referral clinics. These children are offered surgical correction as published reports indicate such therapy is quite satisfactory. This study reports the results of operative intervention (1953 to 1984) at the University Hospital (UH) and National Chest Hospital (NCH). A study of all children (<13 years) subjected to surgical correction of PDA was undertaken to evaluate the results of this operation. There were 140 females and 72 males and their ages ranged from a few weeks to 12 years (mean 4.6 years). A clinical diagnosis of PDA was made in all patients. Forty-two children were subjected to cardiac catheterisation to confirm the clinical diagnosis and/or to exclude other cardio-vascular abnormalities. Anaesthetic management included a balanced technique and induced moderate arterial hypotension to facilitate the great vessel surgery. The operative procedures performed were as follows:- PDA division + suture - 151; PDA ligitation - 48; PDA division + suture & coarctation repair - 5; PDA division + suture & sub-aortic stenosis repair (OHS) - 1; PDA aneurysm repair with LA-femoral bypass - 1; No PDA at thoracotomy - 6, --division of ligamentum arteriosum, --repair of aorto-pulmonary fistulae (OHS) -1, --subsequent repair of VSD (OHS). (OHS = open heart surgery with cardio-pulmonary bypass). There was 1 intra-operative death (<0.5 per cent mortality) due to bleeding from a torn ductus (in 1965) and 1 post-operative death (<0.5 per cent mortality) caused by digoxin toxicity which occurred on day 1 in the convalescent ward. The clinical diagnosis of PDA is accurate (96.5 per cent), and the techniques of anaesthesia and surgery are associated with low morbidity and mortality. Children with PDA should therefore be considered for surgical correction (AU)