Primary Retroperitoneal Serous Cyst Adenoma: A Case Report and Literature Review.

Primary retroperitoneal serous cyst adenomas (PRSCs) are extremely rare thin-walled cystic lesions whose pathogenesis is not well understood. Clinical presentation varies depending on the lesion's size and location, i.e., larger lesions compress adjacent organs, giving the impression of malignancy. Although advances in imaging techniques enable to identify various characteristics of retroperitoneal cystic lesions, there are no pathognomonic signs to confirm the diagnosis. The exact diagnosis is based on the histology after complete surgical excision. An open surgical approach is considered the traditional method of complete resection; however, laparoscopic techniques have increasingly been employed. Diagnostic aspiration is discouraged due to the potential risk of seeding if the lesion is malignant. We present the case of a 51-year-old woman who underwent complete excision of a large right retroperitoneal cyst, histologically confirmed as PRSC with a review of the background and management options of this phenomenon.

Acute Gastric Dilatation With Ischemia and Perforation Requiring Emergency Total Gastrectomy: A Case of Suspected Abdominal Compartment Syndrome.

Acute gastric dilatation is an uncommon surgical pathology, leading to gastric ischemia, necrosis, perforation, sepsis, and death if untreated. While rare, the development of abdominal compartment syndrome is also a devastating complication of this entity. We present a case of a 42-year-old male with a history of gastric volvulus, presenting with severe acute abdominal distension and multi-organ failure. A diagnosis of acute gastric dilatation was made, with suspicion of abdominal compartment syndrome. Emergency laparotomy was performed when nasogastric decompression failed. Total gastrectomy without anastomosis was performed due to the patient's hemodynamic instability. However, he demised shortly after on the operating table. This case report demonstrates that even with rapid diagnosis and management, acute gastric dilatation continues to be associated with high mortality.

Characteristics and Ethnic Distribution of Aortic Aneurysms in a Caribbean Cohort.

BACKGROUND: There is a paucity of data regarding relationships between patient demographics and aneurysm characteristics in the West Indies. With this in mind, a retrospective cross-sectional review was conducted analyzing the computed tomography aortogram reports/images of 273 aortic aneurysms. METHODS: Data were collected and analyzed on ethnicity, size, type, morphology, presence and maximum size of thrombus and aneurysm location, demographics, and clinical presentation with correlations. RESULTS: There were 273 patients with aortic aneurysms giving an incidence rate of 4.33 per 100,000 people per annum. Statistically significant associations were noted with age, gender, and ethnicity. All false aneurysms were male (p = 0.004). The average size of aortic aneurysms being 0.7 cm larger in males than females (p < 0.001). Females were more likely to present with rupture (p = 0.001). Thrombus was more likely in males, Black and mixed races, and in the 8th decade (p < 0.001). Mean age of presentation was the highest in East Indians at 78 than the other ethnicities (Chinese: 65, Black: 70, mixed: 71, White: 73). CONCLUSION: Aortic aneurysmal disease is increasing in Trinidad and the Caribbean. Infrarenal fusiform aneurysms are the most common types with many significant differences based on age, gender, and ethnicity in the Caribbean population.

Necrotizing Soft Tissue Infections of the Breast: A Potentially Lethal Surgical Emergency.

Necrotizing soft tissue infection (NSTI) of the breast is an extremely rare event in surgical practice. It is considered the most aggressive form of soft tissue infection and a true surgical emergency. It is also associated with a high risk of mortality if not diagnosed promptly. Few cases have been documented in the literature; the exact etiology and risk factors vary from those involving the limbs, trunk, and perineum. Early recognition, prompt surgical treatment, and broad-spectrum antibiotic therapy are crucial for reducing morbidity and mortality. These reports present cases of NSTIs in breasts with unique etiologies and challenges in their management.

Endovascular Revascularization and Outcomes of Critical Limb-Threatening Ischemia in Trinidad and Tobago: The EVENT Pilot Study-Challenges in a Limited-Resource, Caribbean Setting.

INTRODUCTION: This retrospective study investigated major adverse limb events (MALE) and mortality outcomes in critical limb-threatening ischemia (CLTI) patients with tissue loss after an endovascular revascularization-first (EVR-1st) strategy. METHODS: MALE and mortality were assessed in 157 consecutive patients with CLTI and tissue loss from June 2019 to June 2022 at the Eric Williams Medical Sciences Complex, Trinidad and Tobago. RESULTS: 157 patients underwent the EVR-1st strategy, of whom 20 were pivoted to immediate surgical revascularization (SR). Of the remaining 137 patients, successful EVR was achieved in 112, giving a procedural success of 82% and an all-comer overall success of 71%. The mortality and MALE rates were 2.7% and 8.9% at 2 years, respectively. Males and patients with previous major amputations were at significantly higher risk for MALE (p values of 0.016 and 0.018, respectively). There was a statistically significant difference in successful EVR for both Rutherford-Baker (RB) 5 (minor) and RB 6 (major) classifications: 63 (56%) vs. 5 (20%) and 49 (44%) vs. 20 (80%), both with a p value of 0.01. There were no differences in successful EVR amongst Wound, Ischemia, Foot Infection (WIfI) clinical stages. There were no differences in successful EVR amongst the Trans-Atlantic Inter-Society Consensus (TASC II) classifications. CONCLUSIONS: This study may prove clinically informative and applicable for an EVR-1st management strategy for high-risk patients with CLTI in a limited-resource, Caribbean setting. TRIAL REGISTRATION NUMBER: NCT05547022 (retrospectively registered).

Gender Influence on Abdominal Aortic Aneurysm Surgery in a Caribbean Population.

Female patients with abdominal aortic aneurysms (AAAs) are usually less common and older than their male counterparts. We report on AAA disease in a Caribbean nation with respect to gender and review their outcomes relative to the male population. Data were collected prospectively and analyzed retrospectively for patients with AAAs who underwent surgery from 2001 to 2018. Sixty patients were diagnosed with AAA with 44 going on to have surgical repair of which 35 were males, aged 61 to 89 (mean age 73.4 years). Nine women ages 44 to 74 years (mean age 60.8 years) had surgical intervention, three being between 40 and 49 years. The size of aneurysms in these patients ranged from 4.3 to 11.0 cm in diameter (average 6.95 cm), female patients having an average diameter of 6.7 cm. Of the 44 patients, 43 underwent open and one endovascular repair. Thirty-three were elective cases and 11 were ruptured with 32 aorto-aortic and 13 aorto-iliac repairs. There were nine fatalities, three elective and six ruptured, with only one being female. Women had similar outcomes to men in all age groups with young patients having good results. Female AAA patients are usually older, undergo less surgical procedures especially if endovascular, and have worse outcomes than their male counterparts. Our study showed that the females were younger but had similar outcomes to the male patients. The female Caribbean patients may present at much younger ages than in continental populations and this may be due to genetic, ethnic, or lifestyle factors.

The Klippel-Trénaunay Syndrome in 2022: Unravelling Its Genetic and Molecular Profile and Its Link to the Limb Overgrowth Syndromes.

The Klippel-Trénaunay syndrome is an unusual syndrome of vascular and dermatologic manifestation in which patients demonstrate hemihypertrophy of the soft tissue and bones of one limb, cutaneous haemangiomas and varicosities in anatomically abnormal positions. Described in 1900 by two French physicians, the etiology remained unclear until recently, when evidence emerged that there was a genetic basis for this sporadic disorder. Genes that encoded pathological angiogenic factors and caused vascular dysmorphogenesis, explaining the molecular bases of this syndrome, were identified. Several angiogenic genes were identified but one gene, the AGGF1 (formerly VG5Q) gene, was seen in mutations involving patients diagnosed with Klippel-Trénaunay syndrome. Furthermore, this syndrome was also noted to have overlapping clinical features linked with the "overgrowth syndromes," in which genetic mutations along somatic lines were identified. These involved The PI3K enzyme which forms part of the phosphoinositide 3-kinase pathway which is encoded by the PIK3CA-gene. This enzyme mediates embryonic cellular growth in-utero and diseases involved in this pathway are classified as members of the PIK3CA-related overgrowth syndrome. This paper reviews the status of what is now known about the molecular genetics of this unusual, but clinically challenging disorder and its differentiation from similar diseases, linked with the PIK3CA-gene and the related overgrowth syndromes.

Comment on 'Achenbach syndrome in an older man'.

We comment on a previous letter regarding Achenbach syndrome, and suggest that punch biopsy should be performed in all clinically suspected cases to obtain histological confirmation of the disease.

Achenbach's Syndrome Revisited: The Paroxysmal Finger Hematoma May Have a Genetic Link.

Achenbach's syndrome describes the sudden occurrence of bruising, pain and swelling of one or more digits of the hand involving the volar aspect of the proximal and middle phalanges. Also known as the paroxysmal finger hematoma, it presents in dramatic fashion, sometimes with a prodrome of tingling, itching or numbness but despite its dramatic presentation, all investigations are normal. Routine blood investigations, as well as coagulation and thrombophilia screens are all negative as are vascular imaging and echocardiography. The diagnosis is solely clinical. Due to the nature of its presentation, almost all patients are referred for an urgent vascular consultation but the condition resolves spontaneously usually within 2-3 days, although the discoloration may persist for longer. Its appearance usually leads clinicians to start anticoagulation in the belief that it may progress but, in fact, it settles as quickly as it appears. Though there are episodic cases which recur years later, it is generally self-resolving with no complications nor residual morbidity. Although the etiology was previously unknown, there is now a recognized genetic link. Genes related to the acute phase reactive proteins and the coagulation and complement cascades appear to be linked to Achenbach's syndrome. This evidence may explain why only certain individuals seem prone to this acutely painful, bruising disorder. We review this interesting disorder and compare patients from the tropical Caribbean region with similar cases from the temperate United Kingdom and discuss whether there are climatic variations in presentations.

Necrotizing Fasciitis of the Breast Requiring a Life-Saving Mastectomy: A Case Report and Literature Review.

Necrotizing soft tissue infection of the breast is an extremely rare event in routine surgical practice. It is the most aggressive form of soft tissue infection and a real surgical emergency. It is associated with a high risk of mortality if not diagnosed promptly. A Literature search has revealed only a few such cases. The exact etiology is variable and very often multifactorial. Early recognition and prompt surgical treatment along with broad-spectrum antibiotic therapy are of paramount importance to prevent mortality. In this report, we present the first case of necrotizing fasciitis of the breast following an insect bite in the literature, in a 57-year-old diabetic patient with a delayed presentation that required a life-saving mastectomy.

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

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

Congenital Dual Internal Hernias Causing Small Bowel Obstruction in a Man with no Prior Surgical History: A Report of a Very Rare Case.

BACKGROUND Internal hernias involve protrusion of the small bowel through a peritoneal or mesenteric space in the abdominal or pelvic cavity. Congenital internal small bowel hernias are rare and patients with them usually present with small bowel obstruction (SBO) at a young age, whereas in older patients, internal small bowel hernias usually are acquired secondary to previous surgery. The present report is of a rare case of SBO due to dual congenital internal small bowel hernias in a 51-year-old man with no history of abdominal surgery. CASE REPORT We report a case of dual congenital internal hernias of the small bowel in a patient who presented with symptoms and signs of SBO. He had no history of abdominal trauma, surgery, or comorbid conditions. His abdomen was mildly distended with minimal tenderness in the upper left quadrant but there was no guarding or rebound tenderness. Abdominal X-rays confirmed the SBO. A contrast-enhanced computed tomography scan of the patient's abdomen revealed SBO with transition at 2 points, suggestive of a closed-loop obstruction. However, the exact cause of the SBO was confirmed at laparotomy, which revealed dual internal hernias (intramesosigmoid and paraduodenal). The hernias were managed individually and the patient had a successful outcome after surgery. CONCLUSIONS Although the present report is of a rare presentation of internal small bowel hernia, the case underscores that patients with this condition may present with SBO. Successful surgical management requires knowledge of the intra-abdominal peritoneal spaces and management of the hernia sac.

Arterial Embolism in Malignancy: The Role of Surgery.

BACKGROUND: Peripheral arterial embolism from malignant disease is uncommon and a rare cause of limb ischemia. In the acute setting, patients can present with severe ischemia of either the upper or lower limb, and urgent surgical intervention is often required to avoid severe debilitation and limb loss. PATIENTS: Our case series comprised three patients who presented with upper and lower limb ischemia and were found to have concomitant malignancy. All three patients were female, with a median age of 54.3 years, and none of the patients was on active chemotherapy. One presented with stage IIb uterine carcinoma, one with stage IIIb ovarian carcinoma, and the other with stage IIIb cervical carcinoma. These patients were referred for vascular management, with two being acute and the other acute on chronic. RESULTS: Of the three patients, two presented with acute limb ischemia and underwent arterial thrombectomy, one of the upper and the other the lower limb. The third patient, with acute-on-chronic upper limb ischemia, was treated conservatively with intravenous heparin followed by oral anticoagulation. All three had limb salvage and survival outcome at 1 year post-treatment. CONCLUSION: In this small series, surgical intervention in two patients and conservative management in the other patient led to limb salvage with a reasonably good quality of life. Even though the long-term survival for patients with malignant disease is generally poor, surgical intervention can achieve limb salvage with a reasonably good quality of life.

Local Repair of a Secondary Aortoenteric Fistula in an Unstable Patient in a Resource-Poor Setting: A Case Report and Literature Review.

The presentation of a massive upper gastrointestinal bleed (UGIB) due to an aortoenteric fistula (AEF) is a rare occurrence. A high index of suspicion is required to rapidly make the diagnosis and execute prompt surgical management. Despite the many surgical options described, the survival rate continues to be low. Conventional surgical management is associated with a high morbidity and mortality. However, in emergencies, patients are unsuitable for major vascular surgery and may benefit from the less invasive staged procedure. This is a case report of a secondary aortoenteric fistula (SAEF) presenting as a massive UGIB, two years after an abdominal aortic aneurysm repair using a Dacron graft. Due to a lack of endovascular service in our setting, we proceeded with an upper gastrointestinal endoscopy followed by exploratory laparotomy. A damage control approach was chosen for our patient, i.e., local repair of the graft and aorta, as our patient was on double inotropes on the table. The patient died within 24 hours as a result of massive blood volume loss.

The rendezvous technique for the treatment of ipsilateral femoral neck and shaft fractures: A case series.

Concomitant ipsilateral femoral neck and shaft fractures are uncommon high-energy injuries characteristically occurring in young adults. Between 75 and 100% of these injuries occur in association with polytrauma to other organ systems. Associated femoral neck fractures are typically undisplaced, occurring in 2-9% of all femoral shaft fractures. These injuries present both technical and infrastructural challenges particularly in a low resource environment. Several methods of treatment have been used to successfully treat these fractures but there exists no consensus about the optimal management strategy. The "rendezvous" technique using dual implants in an overlapping fashion has been proposed as one method to treat these fractures. We present three cases of ipsilateral hip and femoral shaft fractures which were satisfactorily treated using this technique. The "rendezvous" technique is a simple method, with a good clinical outcome and a low complication rate that can be used to treat ipsilateral femoral neck and shaft fractures.

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

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

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

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

The Impact of Breast Clinic on the Mastectomy and Axillary Clearance Rates at a Tertiary Hospital in an Eastern Caribbean Nation: A Comparative Study.

BACKGROUND: Breast cancer is the leading form of cancer in women in Trinidad and Tobago. Traditionally the practice of mastectomy or wide local excision with or without axillary clearance was applied to most of these patients. This is often associated with significant morbidity and a poor cosmetic outcome with both negatively impacting the patients quality of life. The aim of our study was to assess the mastectomy and axillary clearance rate before and after the introduction of a specialty breast clinic in September 2012. DESIGN AND METHODS: This is a retrospective comparative study of all female patients who underwent breast cancer surgery at our tertiary hospital 3 years prior to and 3 years after starting of breast clinic (between January 2010 and December 2015). Patients were identified from the surgical log books of our hospital. There are 5 surgical units at our hospital and in one of those units the lead surgeon had a special interest in surgical oncoplastic breast surgery. That unit formed the breast clinic in August 2012. RESULTS: There were 532 women (256 before breast clinic and 276 after breast clinic era) with histologically verified breast cancer operated on between January 2010 and December 2015. The overall mastectomy rate was reduced from 62% to 51% (0.7 to 0.4) and the axillary clearance rate from 66.79% versus 37.31% (0.6 to 0.4) after the introduction of the clinic with p values of 0.007 and 0.009, respectively. CONCLUSIONS: The introduction of breast clinic has significantly reduced the mastectomy and axillary clearance rate at our teaching hospital.

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

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