Venous drainage of the left liver: an evaluation of anatomical variants and their clinical relevance.

AIM: To evaluate the variations in venous drainage from the left liver. MATERIALS AND METHODS: A retrospective evaluation was performed of all consecutive abdominal computed tomography (CT) examinations at a tertiary referral facility between 1 January and 30 June 2018. Osirix (Pixmeo SARL, Bernex, Switzerland) was used to examine the major hepatic veins and their tributaries in each scan. The classification of variants as proposed by Nakamura and Tsuzuki was used to describe the findings. The following information was collected: ramification pattern, number, length and diameter of middle (MHV) and left (LHV) hepatic vein tributaries. Two researchers collected data independently, and the average measurements were used as the final dimensions. RESULTS: Of 102 examinations evaluated, only 27 demonstrated the conventional venous drainage patterns. The LHV and MHV combined to form a common trunk that emptied into the inferior vena cava (IVC) in 75 (73.5%) cases. The common trunk had a mean length of 8.89 mm and mean diameter of 20.18 mm. Other patterns included Nakamura and Tsuzuki type I (27.5%), type II (29.4%) and type III variants (16.7%). In addition, 4.9% of patients had absent superior middle veins and 80% had supernumerary short hepatic veins (4%). CONCLUSION: Only 26.5% of patients in this population had conventional venous drainage from the left liver. Surgeons and radiologists in hepatobiliary practice should be aware of these variants in order to minimise morbidity when performing invasive procedures.

Management of symptomatic gallstone disease: Equity between two healthcare delivery systems in Trinidad & Tobago

Objective: Patients with symptomatic gallstones require laparoscopic cholecystectomy (LC) to remove the gallbladder to avoid complications. LC should be performed with as little delay as possible. We sought to determine whether the health care delivery systems in Trinidad & Tobago were adhering to best practices. Design and Methodology: At a public and a private institution, the general surgical operating theatre registers were reviewed for the period Jan 2016 to Aug 2018 to identify all patients having undergone LC. Hospital records were then retrieved and retrospectively reviewed. The following data were extracted: patient demographics, index diagnosis, date of index diagnosis, interval between index diagnosis and LC, complications between index diagnosis and LC, duration of LC, complications after LC. Results: 98 patients were studied from both centers with a mean age of 44.8 years ± 12.4(SD) and 92.8% were female. The most common indication for cholecystectomy overall was biliary colic (31.6%). For patients with biliary colic, the mean waiting time for LC was 289.3 days ± 521.5 (SD) days at the public institution compared to 9 days ± 6 (SD). Acute cholecystitis accounted for 30% of diagnoses at both centers. The mean waiting times for patients who presented with acute cholecystitis was 392.9 ± 876.2 days (mean ± SD) in the public healthcare system vs 26.1 ±27.3 days (mean ± SD) in the private healthcare system. Conclusions: There is some disparity in management of symptomatic gallstones between the private and public healthcare systems in Trinidad & Tobago. Specifically, a statistically significant difference in waiting times to complete LC exists between the systems.

Diabetic mastopathy: an uncommon complication of diabetes mellitus.

Introduction. Whilst most consequences of diabetes mellitus are well recognized, breast-related complications remain obscure. The term diabetic mastopathy (DMP) attempts to describe the breast-related consequences of diabetes. Methods. We report the clinicopathologic findings in a patient with DMP and review the literature on this uncommon entity. Results. A 33-year-old woman with type 1 diabetes had excision biopsy of a 2 cm breast lump. Histopathologic evaluation revealed classic features of DMP: parenchymal fibrosis; keloid-like hyalinization of interlobular stroma; adipose tissue entrapment; lobular compression; dense chronic inflammatory cell infiltration; and lymphoid follicle formation. Conclusion. Clinicians should be aware of DMP as a differential for breast disease in women with uncontrolled diabetes.

Variants of hepatic arterial supply in a Caribbean population: a computed tomography based study.

AIM: To evaluate the spectrum of hepatic arterial variants in unselected patients undergoing computed tomography (CT) of the abdomen at the main regional referral centre in the northern Anglophone Caribbean. MATERIALS AND METHODS: Two radiologists independently reviewed 309 CT angiographic studies performed over 2 years between 1 July 2010 and 30 June 2012 at a regional hepatobiliary referral centre for the Northern Caribbean. The anatomical variations were described according to a conventional classification proposed by Michels et al. RESULTS: In this Caribbean population, the majority of patients had conventional Michels' type 1 vascular anatomy (63.4%). However, a statistically significantly greater incidence of Michels' type 2 variations (20.4%) were found than that reported in the international literature and a lower incidence of type 3 (5.2%), type 6 (0.6%), and type 9 (0) patterns than previously reported. One case with variations not previously described in this classification was also encountered. CONCLUSION: Although 63.4% of persons in a Caribbean population have conventional vascular anatomy, the distribution of anatomical variants is quite different to that seen in North American and European centres. Interventional radiologists and hepatobiliary surgeons practicing in the Caribbean must be cognizant of these differences in order to minimize morbidity and mortality during invasive procedures.

The history of laparoscopic general surgery in the Caribbean.

OBJECTIVE: The first world witnessed a laparoscopic revolution in the 1990s. At the start, laparoscopic surgery was heavily criticized and ridiculed. Despite this, the specialty has blossomed where almost any procedure can be done laparoscopically with the now obvious tremendous benefit to the patients. The objective of this paper is to examine where the Caribbean is placed relative to the rest of the world in terms of laparoscopic surgery and to understand why we are here. DESIGN AND METHODS: The literature written on laparoscopy in the region was reviewed and contributions were taken from key surgeons in three main islands, Trinidad and Tobago, Barbados and Jamaica. RESULTS: Though the first laparoscopic cholecystectomy in the Caribbean, in most islands, took place in the early 1990s like the rest of the world, there was relative dormancy for at least a decade in Trinidad and Tobago and even longer in other islands with regards to implementing advanced procedures or increasing case volumes. Reasons for this included lack of funding, lack of operating time in public facilities, lack of information of the public and the medical fraternity but most importantly lack of trained laparoscopic surgeons. This last factor was proven to be the key one in Trinidad and Tobago in 2003, Jamaica 2005 and Barbados 2011/12, when the return of trained personel engineered the transition from basic to advanced laparoscopy CONCLUSION: Despite the delay of approximately 10 years in Trinidad and Tobago and 15 years in other islands, the return of trained surgeons has seen a rapid increase in case variety and volumes in laparoscopy. The wheels of motion of the laparoscopic revolution in the Caribbean have finally begun.

Management of breast abscesses in Jamaican women is there need for a paradigm shift?

A paradigm shift from operative to non-operative management of breast abscesses has occurred in surgical centres worldwide. The recent experience in managing these patients at the University Hospital of the West Indies (UHWI) was examined. Data were obtained retrospectively from dockets retrieved from the UHWI medical records department, and were analysed using the SPSS version 11.0 software package for Windows. Seventy-seven patients with breast abscesses presented during the 66-month study period, but complete data were unavailable for seventeen cases. The mean age of the remaining sixty patients was 32 years. There was one male patient. There were no cases of bilateral disease, and the majority was right-sided. Mean white blood cell count at presentation was mildly elevated at 11.9 x 10(9)/L, and had no relationship to method of management or length of stay. There were two cases treated with aspiration and antibiotics only. All other cases were treated with incision and drainage. Culture results were available in forty-four cases, and in 80%, Staphylococcus aureus was identified, with one case of methicillin resistant Staphylococcus aureus. The mean delay to the operating theatre was one day after presentation and the mean length of stay was 4.5 days. Seventeen patients had a 'non-cosmetic' incision. The traditional management of breast abscess provides challenges in terms of delay to the operating theatre and prolonged hospital stays. There is increased expense, as well as loss of productive work hours, associated with this line of treatment. Non-operative management has not traditionally been undertaken in our institution, but it is documented elsewhere to be safe, practical, and results in improved cosmetic outcomes. Prospective protocol-based trials are necessary to identify the patients most suitable for this line of management in a setting with limited resources.

Complete anal sphincter complex disruption from intercourse: A case report and literature review.

INTRODUCTION: Anal sphincter injuries are uncommon injuries outside of obstetric practice - but they may cause disastrous complications. PRESENTATION OF CASE: We present a case of complete anal sphincter disruption from anal intercourse in a 25 year old woman. Clinical management is presented and technical details of the repair are discussed. She had an uneventful post-operative course and good continence after 154 days of follow up. DISCUSSION: This is one of a handful of reported cases of anal sphincter disruption secondary to anal intercourse. The established risk factors in this case included receptive anal intercourse coupled with alcohol use. We review the pertinent surgical principles that should be observed when repairing these injuries, including anatomically correct repair and appropriate suture choice. There is little evidence to support simultaneous faecal diversion for primary repair of acute perineal lacerations. CONCLUSION: Acute post-coital sphincter injuries should be treated operatively on an emergent basis, without diversion because they are low energy injuries with minimal tissue loss and excellent blood supply. Although repair of each injury should be individualized, the majority of these injuries do not require concomitant protective colostomy creation.

The history of laparoscopic general surgery in the Caribbean / Historia de la cirugía general laparoscópica en el Caribe

OBJECTIVE: The first world witnessed a laparoscopic revolution in the 1990s. At the start, laparoscopic surgery was heavily criticized and ridiculed. Despite this, the specialty has blossomed where almost any procedure can be done laparoscopically with the now obvious tremendous benefit to the patients. The objective of this paper is to examine where the Caribbean is placed relative to the rest of the world in terms of laparoscopic surgery and to understand why we are here. DESIGN AND METHODS: The literature written on laparoscopy in the region was reviewed and contributions were taken from key surgeons in three main islands, Trinidad and Tobago, Barbados and Jamaica. RESULTS: Though the first laparoscopic cholecystectomy in the Caribbean, in most islands, took place in the early 1990s like the rest of the world, there was relative dormancy for at least a decade in Trinidad and Tobago and even longer in other islands with regards to implementing advanced procedures or increasing case volumes. Reasons for this included lack of funding, lack of operating time in public facilities, lack of information of the public and the medical fraternity but most importantly lack of trained laparoscopic surgeons. This last factor was proven to be the key one in Trinidad and Tobago in 2003, Jamaica 2005 and Barbados 2011/12, when the return of trained personel engineered the transition from basic to advanced laparoscopy. CONCLUSION: Despite the delay of approximately 10 years in Trinidad and Tobago and 15 years in other islands, the return of trained surgeons has seen a rapid increase in case variety and volumes in laparoscopy. The wheels of motion of the laparoscopic revolution in the Caribbean have finally begun.

OBJETIVO: El primer mundo fue testigo de una revolución laparoscópica en los años 1990. Al comienzo, la cirugía laparoscópica fue muy criticada y ridiculizada. A pesar de ello, la especialidad ha florecido, siendo el caso que ahora casi cualquier procedimiento puede hacerse laparoscópicamente, con evidentes grandes beneficios para los pacientes. El objetivo de este trabajo es examinar donde se encuentra el Caribe en relación con el resto del mundo en lo que se refiere a la cirugía laparoscópica, y asimismo el por qué nos hallamos en ese lugar. DISEÑO Y MÉTODOS: Se examinó la literatura sobre laparoscopia escrita en la región, y se tomaron contribuciones de cirujanos claves de tres islas principales, a saber, Trinidad y Tobago, Barbados y Jamaica. RESULTADOS: Aunque las primeras colecistectomías laparoscópicas en la mayoría de las islas del Caribe, tuvieron lugar a principio de los años 1990 como en el resto del mundo, hubo un período de relativa inactividad por espacio de casi una década en Trinidad y Tobago, y aun por más largo tiempo en otras islas, en relación con la implementación de procedimientos avanzados o el aumento del volumen de casos. Las razones para esta relativa inactividad incluyeron la falta de fondos, la falta de tiempo de operación de los centros públicos, la falta de información del público y la fraternidad médica, pero sobre todo la falta de cirujanos entrenados en laparoscopia. Esto ultimo resultó ser el factor clave en Trinidad y Tobago en 2003, Jamaica en 2005 y Barbados en 2011/12, cuando el regreso del personal entrenado hizo técnicamente posible la transición de una laparoscopia básica a una avanzada. CONCLUSIÓN: A pesar de la demora de aproximadamente 10 años en Trinidad and Tobago, y de 15 años en las otras islas, el regreso de los cirujanos entrenados ha visto un rápido aumento en la variedad casos y los volúmenes de laparoscopia. El motor de la revolución laparoscópica en el Caribe ha por fin echado a andar.

Factors related to obstetric third and fourth degree perineal lacerations in a Jamaican cohort.

OBJECTIVES: The aim of this study was to identify significant and modifiable risk factors associated with obstetric third and fourth degree perineal lacerations and to produce recommendations that may reduce their morbidity and prevalence. METHODS: This is a retrospective case control study performed between March 2004 and March 2008. All patients diagnosed with third and fourth degree perineal lacerations were identified (cases) along with randomly assigned controls who delivered during the same time period. Nineteen cases and 38 controls were identified giving a total of 57 patients. Each patient's hospital record was collected and the data extracted. RESULTS: When analysed for weight greater than or equal to 3.5 kg versus birthweight of less than 3.5 kg, the difference between cases and controls was found to be statistically significant, with a p-value of 0.012. Of the cases, 21% had an operative delivery (forceps or vacuum) whereas only 2.6% of the controls had an operative delivery. This was found to be statistically significant (p = 0.011). CONCLUSION: This study has shown that the two main factors related to the obstetric third and fourth degree perineal lacerations were babies weighing more than 3.5 kg and the use of forceps or vacuum to assist with deliveries. These high risk patients should be attended to by the most senior staff that is available.

Complicated head trauma from machete wounds: the experience from a tertiary referral hospital in Jamaica.

There have been limited reports on machete wounds to the cranium. This study was carried out to document the injury profile in a series of patients who have sustained cranial injuries from machete wounds in this setting. Between 1 January 1998 and 1 January 2008, demographic and clinical data were retrospectively collected from all patients treated with complicated head injuries from machete wounds with at least one of the following clinical or radiological features: a recorded Glasgow Coma Score < 8 at any point during admission; compound skull fractures; protruding brain matter; cerebrospinal fluid (CSF) leaks; intra-cranial bleeding; parenchymal contusions; lacerations and/or oedema. The data were analysed using the SPSS version 12.0. Of the 40 patients with complex injuries to the cranium, there was a 6:1 male preponderance with a mean age of 32.5 ± 13.7 years (Mean ± SD). The injuries included open skull fractures in all the 40 (100%) patients, depressed skull fractures in 20 (50%) patients, CSF leaks in 4 (10%) patients, protruding brain matter in 4 (10%) patients, cerebral contusions in 3 (7.5%) patients and extra cranial injuries in 16 (40%) patients. Tetanus prophylaxis and intravenous antibiotics were administered to all patients, and phenytoin was required in 16 (40%) cases. There were 37 (92%) patients requiring operative intervention at a mean of 10.4 h after presentation (SD ± 18.1; Median 6). The operative procedures included elevation of depressed fractures in 20 (54.1%) patients, dural repair in 10 (27.0%) patients and intra-cranial debridement in 7 (18.9%) patients. There were three deaths (7.5%), and seizures were recorded in 5 (12.5%) cases with no reports of infectious morbidity. Eighty percent of patients had a normal Glasgow outcome score on discharge. Complicated machete head trauma is uncommon at this health care facility in Jamaica. We achieved a satisfactory outcome with aggressive management consisting of prompt assessment of the extent of injury, appropriate antibiotics, anticonvulsants for those with seizures or cortical injury and early operation to decrease the risk of complications.

Laparoscopic colectomy for colonic neoplasms in a developing country.

AIM: To report the outcome of patients treated for colonic neoplasms using a laparoscopic assisted technique since its introduction at the University Hospital of the West Indies, Jamaica. SUBJECTS AND METHODS: All consecutive patients undergoing laparoscopic assisted colectomy were entered into a prospective database and this data analysed. Data collected included patient demographics, pre-operative diagnosis, operative events, post-operative morbidity and outcome. RESULTS: Over the thirty-six months period July 1, 2005-December 31, 2005 and July 1, 2006-December 31, 2008, thirty patients each underwent laparoscopic assisted colectomy for a colonic neoplasm. Their mean age was 63 years with M: F ratio of 1:2. Seventy-four per cent of the patients had carcinomas which was located on the right and sigmoid colon in 17 and 10 patients respectively. Mean operative time was 98 min for patients with right-sided lesions and blood loss for the entire group was minimal. Two patients were converted to open resections. Median duration of hospitalization was five days. There was no mortality but three patients had complications. After median follow-up of 30 months, there was no local or systemic recurrence. CONCLUSIONS: Appropriately selected patients with colonic neoplasms can be safely subjected to a laparoscopic assisted resection and expect to enjoy the advantages of this technique even in a developing country setting. The outcome of thirty consecutive laparoscopic assisted colectomies is reported demonstrating that this technique can be safely applied to selected patients with colonic carcinomas in developing countries.

Factors related to obstetric third and fourth degree perineal lacerations in a jamaican cohort / Factores relacionados con las laceraciones perineales obstétricas de tercer y cuarto grado en una cohorte de Jamaica

OBJECTIVES: The aim of this study was to identify significant and modifiable risk factors associated with obstetric third and fourth degree perineal lacerations and to produce recommendations that may reduce their morbidity and prevalence. METHODS: This is a retrospective case control study performed between March 2004 and March 2008. All patients diagnosed with third and fourth degree perineal lacerations were identified (cases) along with randomly assigned controls who delivered during the same time period. Nineteen cases and 38 controls were identified giving a total of 57 patients. Each patient's hospital record was collected and the data extracted. RESULTS: When analysed for weight greater than or equal to 3.5 kg versus birthweight of less than 3.5 kg, the difference between cases and controls was found to be statistically significant, with a p value of 0.012. Of the cases, 21% had an operative delivery (forceps or vacuum) whereas only 2.6% of the controls had an operative delivery. This was found to be statistically significant (p = 0.011). CONCLUSIONS: This study has shown that the two main factors related to the obstetric third and fourth degree perineal lacerations were babies weighing more than 3.5 kg and the use of forceps or vacuum to assist with deliveries. These high risk patients should be attended to by the most senior staff that is available.

OBJETIVOS: El objetivo de este estudio fue identificar factores de riesgo modificables y significativos asociados con las laceraciones perineales obstétricas de 3er y 4to grado, y producir recomendaciones que puedan reducir su morbilidad y prevalencia. MÉTODOS: Se trata de un estudio de caso control retrospectivo realizado entre marzo de 2004 y marzo de 2008. Todas las pacientes diagnosticadas con laceraciones perineales de 3er y 4to grado fueron identificadas (casos) con controles asignados de manera aleatoria, que tuvieron el parto en el mismo período de tiempo. Diecinueve casos y 38 controles fueron identificados, para un total de 57 pacientes. Se recogieron y se extrajeron los datos de las historias clínicas de cada paciente. RESULTADOS: Al analizárseles en términos de peso superior o igual a 3.5 kg frente a un peso al nacer por debajo de 3.5 kg, la diferencia entre los controles y los casos resultó ser estadísticamente significativa, con un valor p de 0.012. De los casos, el 21% tuvo un parto operativo (fórceps o vacío), mientras que sólo el 2.6% de los controles tuvo un parto operativo. Esto resultó ser estadísticamente significativo (p = 0.011). CONCLUSIONES: Este estudio ha demostrado que los dos factores principales relacionados con las laceraciones perineales obstétricos de 3er y 4to grado, eran bebés con un peso de más de 3.5 kg y el uso de fórceps o vacío en la asistencia a los partos. Estos pacientes de alto riesgo deben ser atendidos por el personal disponible de mayor experiencia.

Bilateral psoas abscesses and vertebral osteomyelitis in a patient with sickle cell disease.

The authors present a case of a patient with sickle-ß thalassaemia (Sß(0) Thal) who had bilateral psoas abscesses on a background of splenectomy in early childhood. The patient also turned out to have vertebral osteomyelitis and hydronephrosis on the side of the larger abscess. The only organism recovered from the patient was a Bacteroides species. The patient was managed with percutaneous drainage and intravenous antibiotics and made a full recovery.

Motorcycle accident injury profiles in Jamaica: an audit from the University Hospital of the West Indies.

There is little data available on the prevalence of motorcycle accidents, their resultant injuries and the demand on the health care services in Jamaica. We performed a descriptive, analytical study to evaluate the extent of this problem and the need for preventative national policy measures. Between 1 January 2000 and 1 January 2007, demographic and clinical data on all motorcycle accident victims admitted to the University Hospital of the West Indies were collected in a prospective database. The data were analysed using the SPSS version 12.0. Of 270 motorcycle accident victims, there were 257 (95.2%) males and 13 (4.8%) females. Overall, 134 (49.6%) victims wore helmets at the time of their accident. The more common injuries were as follows: soft tissue trauma 270 (100%); head injuries 143 (53.0%); long bone fractures 126 (46.7%); abdominal injuries 38 (14.1%); thoracic injuries 71 (26.3%); vascular injuries 11 (4.1%). The mean injury severity score was 9.0 (SD 9.4; Median 8; Mode 4). There were 195 patients needing surgical intervention in the form of orthopaedic operations (94), neurosurgical operations (43), abdominal operations (49) and vascular operations (14). The mean duration of hospitalisation was 10 days (SD 11.2; Range 0-115; Median 6; Mode 3). There were 12 (4.4%) deaths, 9 (75%) due to traumatic brain injuries. Fatal injuries were more common in males (11) and un-helmeted patients (10). Motorcycle accidents take a heavy toll on this health care facility in Jamaica. Measures to prevent motorcycle accidents and reduce consequent injuries may be one way in which legislators can preserve precious resources that are spent during these incidents. This can be achieved through active measures such as educational campaigns, adherence to traffic regulations and enforcement of helmet laws.

Delays in presentations of stroke patients at the University Hospital of the West Indies.

Thrombolytic therapy has been proven to be beneficial in selected patients with ischaemic strokes. Early diagnosis is paramount because there is a narrow therapeutic window for these patients to derive benefit from thrombolytics. We sought to evaluate the timing of stroke presentations at the University Hospital of the West Indies (UHWI) in order to assess the potential eligibility for definitive therapy A retrospective audit of all consecutive patients who had emergent computed tomographic (CT) scans for suspected ischaemic stroke at the UHWI was performed over a six-month period between February 2006 and July 2006. Data were extracted from the hospital records and analysed using SPSS version 12. There were 331 patients evaluated with brain CT for a clinically suspected stroke during the study period. Complete time documentation and CT scans were available for analysis in 171 patients with ischaemic strokes. The average age was 64.5 years (range +/- SD: 3-98 +/- 19.9 years) with a slight male preponderance (58% vs. 42%). There was considerable pre-hospital delay with 63% of patients presenting more than 12 hours after the onset of symptoms. There were also long inhospital delays. Only 52% of patients were assessed by a physician within an hour of presentation to hospital and only 55% of patients had CT scans completed within three hours of a physician s request. Although thrombolysis is not routinely performed for ischaemic strokes at our institution, sensitization of physicians and the general public in our setting to symptoms and signs of this disease is urgently needed to improve stroke management, whereby definitive treatment can be considered for selected patients.

Management of obstetric anal sphincter injuries at the University Hospital of the West Indies.

Up to 6% of women sustain severe perineal lacerations that involve the anal sphincters during vaginal delivery. When they occur obstetric anal sphincter injuries (OASI) may be accompanied by significant morbidity. Therefore, it is important to detect these injuries promptly and for experienced staff to perform sound repair. This report retrospectively assesses a series of seven women with OASI who were managed at a tertiary level hospital in Jamaica over a period of 28 months. Unfavourable details of management that may have adversely affected outcomes were sought from the various cases treated The incidence of OASI was low (0.2%). There were five third degree and two fourth degree lacerations. After these injuries were repaired, three patients (43%) experienced morbidity such as chronic pelvic pain (43%), anal incontinence (29%), dyspareunia (23%) and recto-vaginal fistulae (14%). In order to improve the outcomes at this institution, several aspects of current care can be improved. Operative repair of these injuries should be delayed until senior staff is available to supervise OASI repair. Both methods of sphincter repair are reasonable options but the use of rapidly absorbable sutures is not appropriate. Finally, prophylaxis against wound infections can be achieved by administering a single dose of intravenous second or third generation cephalosporin at the time of induction of anaesthesia.