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1.
Cureus ; 14(4): e24058, 2022 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-35573550

RESUMEN

Acute pancreatitis (AP) is rarely seen in the paediatric population and is typically not associated with those aetiologies seen in adult pancreatitis. This case describes a 12-year-old female who presented with acute abdominal pain and constipation, with biochemical evidence of elevated serum amylase, calcium (Ca) and parathyroid hormone (PTH) levels. A diagnosis of AP was made, which was settled with conservative management. Further investigations, namely CT and technetium 99m (Tc-99m) sestamibi scans, revealed a solitary parathyroid adenoma. She subsequently underwent minimally invasive parathyroidectomy (MIP), following which Ca and PTH levels normalized postoperatively.

2.
Cureus ; 14(1): e21733, 2022 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-35145827

RESUMEN

Abrikossoff tumors are rare benign soft-tissue lesions also known as granular cell tumors (GCT). The histogenesis of these tumors was initially considered to be myogenic but recent studies have revealed a neuroectodermal origin. GCTs of the breast may mimic breast carcinoma based on the triad of radiological, clinical, and pathological features. This hallmark trait lends to the misdiagnosis of these tumors and their subsequent inappropriate management. We report a rare case of a 28-year-old female patient with an accessory axillary breast GCT. The diagnosis, histogenesis, and management of Abrikossoff tumors of the breast are discussed.

3.
Clin Exp Dermatol ; 47(5): 981-982, 2022 May.
Artículo en Inglés | MEDLINE | ID: mdl-34994981

RESUMEN

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.


Asunto(s)
Neoplasias Cutáneas , Biopsia , Hematoma , Humanos , Masculino , Piel/patología , Neoplasias Cutáneas/patología , Síndrome
4.
Trop Doct ; 52(1): 101-103, 2022 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-34474625

RESUMEN

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.


Asunto(s)
COVID-19 , Tutoría , Cirujanos , COVID-19/epidemiología , COVID-19/prevención & control , Humanos , Pandemias/prevención & control , SARS-CoV-2
5.
Vasc Health Risk Manag ; 17: 809-816, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34934323

RESUMEN

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.


Asunto(s)
Dedos/irrigación sanguínea , Hematoma/etiología , Diagnóstico Diferencial , Traumatismos de los Dedos/complicaciones , Hematoma/diagnóstico por imagen , Hematoma/genética , Hematoma/patología , Humanos , Dolor , Recurrencia , Síndrome
6.
Cureus ; 13(11): e19886, 2021 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-34966604

RESUMEN

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.

7.
Am J Case Rep ; 22: e933754, 2021 Dec 28.
Artículo en Inglés | MEDLINE | ID: mdl-34961759

RESUMEN

BACKGROUND Upper limb replantation has become an almost routine procedure, with digital and hand reattachments being the most commonly performed. These remain challenging procedures to reconstructive surgeons, especially when there is trauma to the detached limb. Injury to the overlying skin and soft tissue can lead to tissue necrosis, sepsis, and loss of the replanted limb. The use of skin grafts as well as a wide variety of muscular, musculo-cutaneous, fascio-cutaneous flaps, and free-transfer grafts has significantly diminished limb loss. We report on the use of a delayed fascio-cutaneous, pedicled groin flap to cover a defect on the dorsum of a hand replanted 6 weeks earlier. CASE REPORT A right-hand-dominant male laborer had his left hand completely severed by a sharpened machete. This was surgically replanted with limb salvage but there was an area of denuded tissue on the dorsum, devoid of epidermal coverage. A fascio-cutaneous, pedicled rotational flap arising from the left groin was used as definitive cover for the defect. This flap augmented the replantation process by producing a functional and visually acceptable replant, allowing the patient to undergo rehabilitation and eventually return to the workforce. CONCLUSIONS The fascio-cutaneous, pedicled, rotational groin flap is a thin, pliable, but robust flap which covered the defect created by the initial injury with a protective tissue layer. It allowed free movement of the extensor tendons by creating a smooth surface over which they could easily glide with retention of near-normal, functional hand movement.


Asunto(s)
Procedimientos Quirúrgicos Reconstructivos , Traumatismos de los Tejidos Blandos , Adulto , Ingle/cirugía , Humanos , Masculino , Reimplantación , Trasplante de Piel , Traumatismos de los Tejidos Blandos/cirugía , Colgajos Quirúrgicos
8.
Cureus ; 13(10): e18739, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-34790488

RESUMEN

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.​.

9.
Radiol Res Pract ; 2021: 9201162, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34691781

RESUMEN

PURPOSE: There are many known variations in the arterial supply to the liver. We sought to document the incidence and details of anomalies of the extrahepatic arteries in an unselected population in the West Indies. METHODS: This study spanned 24 months. All 205 CT scans were evaluated at a hepatobiliary referral center in Trinidad and Tobago. We described the anomalies of the arterial supply to the liver using the conventional classification proposed by Michels. RESULTS: 205 CT scans were evaluated, and 112 persons (54.6%) had conventional Type 1 anatomy. However, compared to the incidence in the existing medical literature, we encountered a greater incidence of replaced right hepatic arteries (18.1% vs 11%; P 0.04) and a lower incidence of accessory right hepatic arteries (2.4% vs 7%; P 0.030). CONCLUSION: Although 54.6% of persons in this West Indian population have conventional hepatic arterial supply, the distribution of anatomic variants of the right hepatic artery is quite different to that seen in North American and European centers. We found a higher incidence of replaced right hepatic arteries and a lower incidence of accessory right hepatic arteries.

10.
Cureus ; 13(8): e16972, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-34540383

RESUMEN

Major lower extremity amputations have been an area of much concern in the Caribbean population. Hence, the purpose of this research was to investigate the current trends in major lower-extremity amputations. Data regarding all major lower-extremity amputations performed at a tertiary care institution in Trinidad and Tobago, from January 2010 to December 2016 were reviewed. The variation of yearly trends, gender, type of amputation and reason for amputation were analysed. The yearly amputation rate demonstrated a progressive increase from 2010 to 2016, the average for the seven years was 28 per 105/year. Males accounted for 59% of cases, and 60% of amputations were done above the level of the knee joint. The most common reason for amputation was control of sepsis in 71.5% of cases. A strong association between major amputations and prior intervention for a foot-related problem was observed, as 52% of the sample had a pre-existing wound or a prior minor amputation (32%). Overall, 14.5% of all amputees were able to acquire a prosthesis. Diabetes mellitus was the most consistently associated co-morbidity occurring in 91% of the study population. Major limb amputations continue to affect our population significantly, with a rise in the amputation rate despite the introduction of a Vascular Surgical Unit. Diabetes and its foot-related complications are one of the leading causes of major lower extremity amputations. Prosthetic limb acquisition for our amputee population continues to be lacking, reflected by the low prosthetic acquisition rate observed.

11.
Cureus ; 13(7): e16789, 2021 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-34513396

RESUMEN

Previously, the management of gunshot wounds (GSWs) to the anterior abdomen required exploratory laparotomy; however, this was associated with a considerable number of non-therapeutic surgeries. The use of non-operative management (NOM) of GSW to the abdomen is controversial, with many surgeons sceptical to accept this into their practice. The NOM of GSW to the abdomen employed in a selected group of patients has been shown to be safe and acceptable. Penetrating GSW to the thoraco-abdomen, back and lateral abdomen has been the most successful compared to the anterior penetrating wound. Most of the anterior GSWs to the abdomen are associated with viscus injury and require exploratory laparotomy. We report the case of a 58-year-old male who presented with a single GSW to the epigastrium with a contrast computed tomography scan demonstrating grade 3 liver lacerations, contusion to the right adrenal gland, with moderate free fluids in the retroperitoneum and the pelvis. The patient was haemodynamically stable and managed successfully with NOM. It is one of the safe routes of anterior penetration of GSW to the abdomen and treated with conservative management.

12.
Int J Surg Case Rep ; 87: 106408, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-34534815

RESUMEN

INTRODUCTION: Lobular breast cancer (LBC) has an increased risk of gastrointestinal (GI) spread compared with ductal breast carcinoma. Breast cancer commonly metastasises to bone, lung, liver, central nervous system and rarely to the gastrointestinal tract. As the prognosis for breast cancer continues to improve with modern medical practice it is important to be aware of the various clinical presentations and the appropriate management of breast cancer metastases. CASE PRESENTATION: We describe a case of a 60-year-old woman who presented with symptoms of bowel obstruction 30 months after undergoing mastectomy and adjuvant chemotherapy for LBC. A Computer Tomography (CT) scan showed terminal ileal thickening suggestive of Crohn's disease but histopathology revealed metastatic lobular carcinoma. Surgical resection to relieve her small bowel obstruction confirmed LBC. CLINICAL DISCUSSION: This case illustrates an unusual presentation of metastatic breast cancer causing small bowel obstruction with radiological features mimicking Crohn's disease. CONCLUSION: Patients with breast cancer can present with intestinal obstruction due to metastatic spread to the small intestine; this may resemble Crohn's disease clinically and radiologically.

13.
Cureus ; 13(8): e17440, 2021 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-34589346

RESUMEN

Lower extremity amputations and diabetic foot-related complications in the Caribbean population have been previously reported. However, there is a lack of evidence that assess the quality of life experienced in such amputees. This study aimed to determine the health-related quality of life (HRQoL) in patients after a major lower limb amputation. Data collection was performed for all major lower limb amputations undertaken at a tertiary care institution in Trinidad and Tobago, between January 2012 to December 2016. The quality of life for patients who were accessible, alive, and willing to participate was assessed using the EuroQol 5D-5L tool. Statistical analysis was performed using the Mann-Whitney U and Kruskal-Wallis tests comparing medians across various subgroups. A total of 134 individuals were still alive and willing to participate in the study. The average EQ-5D-5L index value for the cohort was (0.598), which was significantly lower compared to EQ-5D-5L population norms for Trinidad and Tobago p < 0.05. Statistically significant differences were also seen in median EQ-5D-5L index value for patients who ambulated with a prosthesis (0.787) compared to those who used another device for mobilization (0.656), p < 0.05, and to those patients who did not ambulate (0.195), p < 0.05. A comparable Quality of life was seen between the level of amputation (transtibial versus transfemoral) and gender (males versus females), p-values were 0.21 and 1.0, respectively. Overall quality of life after major amputation, as well as independent mobilization with a prosthesis, continues to be problematic in the Caribbean population. Factors adversely related to the quality of life post major amputation include increasing age, problems related to mobility, and non-ambulatory patients.

14.
Cureus ; 13(6): e15489, 2021 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-34268021

RESUMEN

During damage control laparotomy, surgery is abbreviated to allow for the correction of physiologic disturbances, with a plan to return to the operating theatre for definitive surgical repair. Re-entry into the abdomen is facilitated by temporary abdominal closure (TAC). Skin-only closure is one of the many techniques described for TAC Numerous sources advise against the use of this technique because of the risk of complications. This case report describes the use of skin-only closure during a damage control laparotomy. We reviewed the literature surrounding the various options for TAC to elucidate the potential role of skin-only closure after damage control laparotomy.

15.
Am J Case Rep ; 22: e932132, 2021 Jul 13.
Artículo en Inglés | MEDLINE | ID: mdl-34255765

RESUMEN

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.


Asunto(s)
Hernia Abdominal , Obstrucción Intestinal , Dolor Abdominal , Hernia Abdominal/complicaciones , Hernia Abdominal/diagnóstico por imagen , Hernia Abdominal/cirugía , Humanos , Hernia Interna , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Intestino Delgado/cirugía , Masculino , Persona de Mediana Edad
16.
Cureus ; 13(5): e14915, 2021 May 09.
Artículo en Inglés | MEDLINE | ID: mdl-34123615

RESUMEN

Watchful waiting (WW) is a strategy that can be used to manage hernias whereby patients who are asymptomatic or minimally symptomatic are observed until symptoms worsen or complications develop, prompting surgical intervention. The successful implementation of a WW strategy requires patients to report changes in their clinical condition to receive timely care. Patients who have severe mental illness may defer seeking care when appropriate. This case report describes our experience treating a patient with severe mental illness who had a primary ventral hernia managed by WW. She was lost to follow-up and subsequently presented with a strangulated epigastric hernia which fistulized to the skin. The case report highlights the challenges of attempting WW in patients with severe mental illness. We suggest that poorly controlled severe mental illness should be considered a relative contraindication to WW.

17.
Ther Clin Risk Manag ; 17: 635-640, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-34177265

RESUMEN

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.

18.
World J Gastrointest Endosc ; 13(6): 170-183, 2021 Jun 16.
Artículo en Inglés | MEDLINE | ID: mdl-34163564

RESUMEN

BACKGROUND: In the classic descriptions of the human liver, the common hepatic duct forms at the confluence of left and right hepatic ducts. Many authors have documented variations in the intra-hepatic ductal system, but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations. AIM: To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography (MRC) in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean. Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders. METHODS: This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean. We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1, 2017 to March 31, 2019. Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang's classification. A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant. The variants in our population were compared to the global population. RESULTS: There were 152 MRCs evaluated in this study in 86 males and 66 females. There were 109 (71.7%) persons with "classic" biliary anatomy (type A1) and variants were present in 43 (28.3%) persons. There was no statistical relationship between the presence of anatomic variants and gender or ethnicity. We encountered the following variants: 29 (19.1%) type A2, 7 (4.6%) type A3, 6 (3.95%) type A4, 0 type A5 and a single variant (quadrification) that did not fit the classification system. Compared to the global prevalence, our population had a significantly greater occurrence of A1 anatomy (71.7% vs 62.6%; P = 0.0227) and A2 trifurcations (19.1% vs 11.5%; P = 0.0069), but a significantly lower incidence of A3 variants (4.61% vs 11.5%; P = 0.0047). CONCLUSION: There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics. Specifically, persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.

19.
World J Transplant ; 11(6): 231-243, 2021 Jun 18.
Artículo en Inglés | MEDLINE | ID: mdl-34164298

RESUMEN

BACKGROUND: Variations in the anatomy of hepatic veins are of interest to transplant surgeons, interventional radiologists, and other medical practitioners who treat liver diseases. The drainage patterns of the right hepatic veins (RHVs) are particularly relevant to transplantation services. AIM: The aim was to identify variations of the patterns of venous drainage from the right side of the liver. To the best of our knowledge, there have been no reports on RHV variations in in a Caribbean population. METHODS: Two radiologists independently reviewed 230 contrast-enhanced computed tomography scans performed in 1 year at a hepatobiliary referral center. Venous outflow patterns were observed and RHV variants were described as: (1) Tributaries of the RHV; (2) Variations at the hepatocaval junction (HCJ); and (3) Accessory RHVs. RESULTS: A total of 118 scans met the inclusion criteria. Only 39% of the scans found conventional anatomy of the main hepatic veins. Accessory RHVs were present 49.2% and included a well-defined inferior RHV draining segment VI (45%) and a middle RHV (4%). At the HCJ, 83 of the 118 (70.3%) had a superior RHV that received no tributaries within 1 cm of the junction (Nakamura and Tsuzuki type I). In 35 individuals (29.7%) there was a short superior RHV with at least one variant tributary. According to the Nakamura and Tsuzuki classification, there were 24 type II variants (20.3%), six type III variants (5.1%) and, five type IV variants (4.2%). CONCLUSION: There was significant variation in RHV patterns in this population, each with important relevance to liver surgery. Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity during invasive procedures.

20.
Trop Doct ; 51(4): 539-541, 2021 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-34162285

RESUMEN

Although laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis, many Caribbean surgeons are reluctant to operate during the acute attack. We collected data for all consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis from January 1 to 31 December 2018. Delayed cholecystectomy was done >6 weeks after acute cholecystitis settled. We compared data between early and delayed groups. Delayed laparoscopic cholecystectomy was performed in 54 patients, and 42 had early laparoscopic cholecystectomy. Delayed surgery resulted in significantly more complications requiring readmission (39% vs 0), longer operations (2.27 vs 0.94 h) and lengthier post-operative hospitalisation (1.84 vs 1.1 days). Caribbean hospitals should abandon the practice of delayed surgery after cholecystitis has settled. Early laparoscopic cholecystectomy would be financially advantageous for our institutions, and it would save patients recurrent attacks of gallstone disease.


Asunto(s)
Colecistectomía Laparoscópica , Colecistitis Aguda , Región del Caribe , Colecistectomía , Colecistectomía Laparoscópica/efectos adversos , Colecistitis Aguda/cirugía , Humanos , Tiempo de Internación , Factores de Tiempo , Resultado del Tratamiento
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