Should Delayed Cholecystectomy Following Acute Calculous Cholecystitis Be Discouraged in a Resource-restricted Setting?

BACKGROUND: Early cholecystectomy for acute calculous cholecystitis (ACC) reduces hospital stay and complications during the waiting period. The purpose of this study is to establish the patterns of management of ACC at the University Hospital of the West Indies (UHWI) and to evaluate the advantages of early versus delayed cholecystectomy. METHODS: This was a retrospective chart review of patients admitted with a diagnosis of ACC. Data collection included demographics, management strategy, timing to cholecystectomy, significant events while awaiting cholecystectomy and duration of hospital stay. Mann-Whitney U and Chi-squared tests were used for analysis. P-value of < 0.05 was considered significant. RESULTS: A total of 102 patient charts were extracted, 59 of which were managed conservatively and 43 managed with early cholecystectomy. The mean time to surgery after conservative management was 173 days. About 30% of persons managed conservatively had significant attacks while awaiting surgery, which included need for re-admission and earlier intervention. There was a trend toward longer mean total hospital stay in the conservative group (xsx = 5.03, xCons = 6.12; p = 0.054). CONCLUSION: Conservative management of ACC results in significant delays in definitive management and risks of complications during the waiting period. Early cholecystectomy should be encouraged even in a resource-restricted setting.

Trauma in the developing world: the jamaican experience.

Trauma remains a challenging burden on the often under-funded healthcare systems of developing countries. Ten-year data from the Jamaica Trauma Registry show that trauma accounts for 20% of surgical admissions, with close to 50% being intentional and with a 5% mortality. There is a good opportunity for various preventive programmes to be instituted to reduce the burden of this disease.

The Impact of Trans-thoracic Ultrasound on Cardiac Injuries.

OBJECTIVE: To determine the impact of trans-thoracic ultrasound (TTUS) in patients with chest trauma and potential cardiac injuries and to determine the outcome of patients with cardiac injury detected on TTUS. METHOD: Data were obtained from the Trauma Registry for all patients presenting alive to the University Hospital of the West Indies during the 10-year period commencing January 1, 2001 and who were subjected to a TTUS or emergency thoracotomy for cardiac injuries, or had cardiac injuries at postmortem. In addition to demographics, variables analysed included mechanism and site of injury and outcome. RESULTS: Of 405 patients being subjected to a TTUS during the period, 12 (3%) had cardiac injuries. During the same period, 63 patients in the Trauma Registry had proven cardiac injuries. Trans-thoracic ultrasound was thus conducted on 19% of all patients with cardiac injuries. Three patients had positive TTUS but no cardiac injuries. Of the patients with injuries, the mean age was 30.4 years, 92.1% were male and 65% were as a result of stab wounds, while 22% were as a result of gunshot wounds. The right ventricle was the most common site of injury, accounting for 41% of cases, while the left ventricle, both ventricles and other sites accounted for 27%, 17% and 14%, respectively. Ninety per cent of the group was subjected to emergency thoracotomy; mortality of the entire group was 48%, including one patient who had TTUS. CONCLUSIONS: This review demonstrates that cardiac injuries remain lethal, diagnosis is largely clinical and TTUS may be over-utilized, having little impact on clinical outcome of patients presenting with this injury.

Dengue fever mimicking acute appendicitis: A case report.

INTRODUCTION: Dengue fever is an acute viral disease, which usually presents as a mild febrile illness. Patients with severe disease present with dengue haemorrhagic fever or dengue toxic shock syndrome. Rarely, it presents with abdominal symptoms mimicking acute appendicitis. We present a case of a male patient presenting with right iliac fossa pain and suspected acute appendicitis that was later diagnosed with dengue fever following a negative appendicectomy. PRESENTATION OF CASE: A 13-year old male patient presented with fever, localized right-sided abdominal pain and vomiting. Abdominal ultrasound was not helpful and appendicectomy was performed due to worsening abdominal signs and an elevated temperature. A normal appendix with enlarged mesenteric nodes was found at surgery. Complete blood count showed thrombocytopenia with leucopenia. Dengue fever was now suspected and confirmed by IgM enzyme-linked immunosorbent assay against dengue virus. DISCUSSION: This unusual presentation of dengue fever mimicking acute appendicitis should be suspected during viral outbreaks and in patients with atypical symptoms and cytopenias on blood evaluation in order to prevent unnecessary surgery. CONCLUSION: This case highlights the occurrence of abdominal symptoms and complications that may accompany dengue fever. Early recognition of dengue fever mimicking acute appendicitis will avoid non-therapeutic operation and the diagnosis may be aided by blood investigations indicating a leucopenia, which is uncommon in patients with suppurative acute appendicitis.

Mucinous cystadenoma of the appendix presenting with an elevated carcinoembryonic antigen (CEA): Report of two cases and review of the literature.

INTRODUCTION: Despite the fact the mucocoele of the appendix is a rare entity it has been the subject of much interest in the literature. The term mucocoele refers to cystic dilatation of the appendix filled with mucin resulting from proximal obstruction of the appendix lumen. PRESENTATION OF CASE: We report two patients presenting with mucinous cystadenoma of the appendix with elevation of serum carcinoembryonic antigen (CEA), which has rarely been reported. Both patients had mild symptoms and a normal colonoscopy preoperatively. The diagnosis was not suspected in one patient prior to surgery. The elevated CEA prompted additional diagnostic radiologic investigations including ultrasonography, and computed tomography scans. The patients had uneventful appendicectomies with subsequent normalization of their CEA levels. DISCUSSION: Mucinous cystadenoma of the appendix is a rare pathological entity characterized by a dilated mucous filled appendix. The presence of an elevated CEA associated with the presence of this entity is a rare presentation. CONCLUSION: Because the diagnosis is rarely suspected prior to surgery patients with an enlarged appendix with associated elevated CEA levels should have careful investigations to exclude malignancy.

Colorectal anastomotic leakage at the university hospital of the west indies: an analysis of risk factors.

BACKGROUND: Anastomotic leakage remains a concern in general surgical practice. The significance lies in the resultant abdominal sepsis, related morbidity and mortality, risk of anastomotic loss, permanent stoma creation and the effect on local recurrence and overall patient survival in colorectal cancer cases. OBJECTIVES: This study serves to determine the leak rates and the mortality thereof related to colonic and rectal anastomoses at the University Hospital of the West Indies (UHWI) in Kingston, Jamaica. Independent factors contributing to anastomotic leaks in these patients will also be assessed and correlations determined. METHODS: A review of the medical records of one hundred and thirty-three cases of colonic and rectal anastomoses identified retrospectively over a three-year period provided relevant information for analysis. RESULTS: Anastomotic leaks were identified in twelve patients, providing a leak rate of 9.0%. No 30-day mortality related to anastomotic leakage was noted. Based on a multivariate analysis, male gender was identified as the sole independent factor related to anastomotic leakage. CONCLUSION: Colorectal anastomotic leak rates at UHWI fell at the upper limit of leak rates typically quoted in the literature. No modifiable risk factor appeared to contribute to this leak rate. Early identification and intervention is critical in limiting mortality associated with colorectal anastomotic leakage.

Adequacy of lymph node harvesting in colorectal cancer management: improving standards, ensuring quality.

OBJECTIVE: The aim of this study was to determine the adequacy of nodal sampling in resection specimens for colorectal carcinoma in a Jamaican population. METHODS: The pathology records of all patients who underwent operation for colorectal carcinoma at the University Hospital of the West Indies (UHWI) during the five-year period, 2003-2007, were reviewed. Pertinent clinical and pathologic data were obtained and analysed. RESULTS: One hundred and ninety-one patients were identified with M:F ratio of 1.1:1 and a mean age of 66 years. There were 119 (63%) left-sided lesions and 70 (37%) right-sided lesions. Stage T3N0 lesions were the most common and accounted for 41.1% of cases. The predominant histologic type was adenocarcinoma (99.5%) with the majority being moderately differentiated. The mean number of nodes sampled in node-negative cases was 13.8 +/- 9.75 nodes for right-sided lesions and 10.64 +/- 7.25 nodes for left-sided lesions (p = 0.05, CI 95%). The adequacy of nodal sampling was acceptable in cases of N0 right-sided carcinomas but was unsatisfactory in cases of N0 left-sided carcinomas. More importantly, however in two cases from the right and 10 cases from the left, two or fewer nodes were harvested. CONCLUSION: This review suggests the need for re-examination of the adequacy of surgical resection and/or nodal sampling technique for colorectal cancer resection specimens, given the importance of nodal status in determining the need for adjuvant therapy. Less than adequate node sampling should not be accepted by the reporting pathologist or attending surgeon as this has important prognostic implications.

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.

Colonoscopy in central Jamaica: results and implications.

The aim of this report was to determine the outcome of all patients subjected to colonoscopy at an outpatient medical facility in central Jamaica. A copy of the colonoscopy report of each consecutive patient during the period March 2007 to April 2011 was entered into a database and analysed. One thousand two hundred and fifty patients were identified with a mean age of 60 years and 56.5% were female. The most common indication for colonoscopy was bleeding (28%) but constipation (15%) and screening (11%) were also important. Caecal intubation was achieved in 96% of the group. While 30% of the group had normal findings, 32% had diverticulosis and 23% had haemorrhoids; importantly 10% had carcinomas and 11% had adenomas. Adenomas were detected in 13% of the screened patients. The most important predictor of an abnormal colonoscopy was a history of bleeding. The perforation rate was 0.24% with no perforations occurring in the latter 650 cases.

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.

Open abdominal aortic aneurysm repair in the era of endovascular repair.

OBJECTIVES: The development of minimally invasive techniques for abdominal aortic aneurysm (AAA) repair and the establishment of specialized centres have resulted in improved patient outcomes. This study examines open AAA repair at a non-specialized centre where advanced techniques are not practised. METHODS: We conducted a retrospective analysis on a cohort of 83 patients presenting for AAA repair to a non-specialized hospital, the University Hospital of the West Indies (UHWI). The end points assessed included operative (30-day) mortality, postoperative complications, duration of operation, blood loss, intensive care unit (ICU) stay and overall hospital stay. RESULTS: The overall operative mortality was 9.4% (23% for ruptured aneurysms and 5% for unruptured aneurysms). Mean operating time, blood loss, ICU stay and hospital stay were 326 +/- 98 minutes, 2420 +/- 1397 mls, 3 +/- 5 days and 9 +/- 5 days, respectively with no significant differences noted between ruptured and unruptured aneurysms. Mean aneurysm diameter was 6.13 +/- 1.59 cm. CONCLUSION: Mortality rates for open aneurysm repair at the UHWI are consistent with findings in the current literature. Open AAA repair remains a safe treatment option in this environment. Continued improvements need to be made with respect to minimizing blood loss and operation duration, particularly in repairs of unruptured aneurysms.

Non-operative management of non-destructive extra-peritoneal rectal injury.

This is a case report of extra-peritoneal rectal injury, secondary to a gunshot, that was managed non-operatively. A 57-year old male presented with a single gunshot to the right buttock and had blood per rectum. Extra-peritoneal rectal injuries were seen on proctoscopy and he had no genitourinary injury. He was managed successfully without rectal injury repair orfaecal stream diversion.

Trauma: the burden of a preventable problem.

Trauma is a leading cause of morbidity and mortality in developing countries and we reviewed the demographics and cost of trauma in a Jamaican population. This is a retrospective, descriptive analytical study of all trauma patients aged 25 to 29-years who presented to the University Hospital of the West Indies (UHWI) during the study period, January 2001 to December 2005. Data were extracted from the Trauma Registry and analysed. Seven hundred and fifteen patients were included in the specified age group over the five-year period. The median age of the patients was 27 years and the median hospital stay was 3 days. There was a 4:1 ratio of males to females and 49.7% of injuries were caused by penetrating wounds. Motor vehicle accidents occurred in 22.4% of cases. Head injuries occurred in 13.6% of cases, long bone fractures in 16.5% and internal injury to chest or abdominal organs in 15.9% of cases. Craniotomy or thoracotomy was undertaken in 4% of cases, Open Reduction Internal Fixation (ORIF) or bone immobilization in 11% and laparotomy in 8% of cases. The mean injury severity scores (ISS) was 4 while 5% of patients had ISS greater than 15. More than 60% of patients underwent diagnostic X-rays, 8% had abdominal imaging (CT scan or ultrasound) and 9.5% underwent head CT scan. The in-hospital mortality was 4.2%. The median hospital bill charged was US$320.00 and the median amount paid by the patients was US$50.00. At the start of the new millennium, penetrating trauma accounted for almost 50% of cases at UHWI with the majority of costs associated with trauma-care being state funded.

Duodenal fibrosarcoma mimicking Franz tumour complicated by post-resection chylous ascites.

This case report presents a young woman who underwent a Whipples resection for a large pan-creato-duodenal tumour. Pathology and immunohistochemical analysis of the tumour suggest duodenal fibrosarcoma. The patient's postoperative management was complicated by chylous ascites. A brief literature review is given to highlight this unusual case.

Emergency subtotal colectomy for lower gastrointestinal haemorrhage: over-utilised or under-estimated?

INTRODUCTION: A minority of patients with unlocalised massive lower gastrointestinal bleeding (LGIB) will require treatment with emergency subtotal colectomy (STC). METHODS: To determine the outcome of STC in this high-risk group, we retrospectively reviewed the histopathology reports and case records of all subtotal colectomies performed for LGIB over a 8-year period. RESULTS: Fifty-eight patients (mean age: 71 years; male to female ratio, 1 : 1) underwent emergency surgery for unlocalised LGIB, 45% of which were massive on admission, and unresponsive to resuscitation. The remainder had persistent or recurrent bleeding during the index hospitalisation. The hospitalisation for colectomy represented the first for LGIB for 56% of the study group, while 38% were on at least their third such admission. All but three patients underwent preoperative rigid proctosigmoidoscopy. Fifty-five of the 58 patients were treated with STC and primary ileorectal anastomosis. The major causes of bleeding were diverticular disease only (68%), angiodysplasia only (12%) and both diseases (12%). Overall mortality was 17%, with the main contributor being sepsis resulting from anastomotic leak. Non-fatal complications occurred in 20%, resulting in a mean postoperative length of stay of 13 days. All patients were doing well on their first follow-up visit with a mean number of four stools per day after 1 month. CONCLUSION: While emergency STC is an effective and definitive method of treating unlocalised massive LGIB, its associated morbidity and mortality may limit its usefulness.

Emergency department thoracotomy in Jamaica: a case controlled study.

Increasing numbers of severely injured patients have been presenting to Emergency Rooms worldwide due to advances in pre-hospital trauma care. Some of these patients may be candidates for Emergency Department Thoracotomy (EDT). Large advisory bodies have identified selection criteria for EDT in Developed Countries, but there are no regional statistics to guide the selection process in Developing Caribbean Nations. This study evaluates outcomes with EDT at the University Hospital of the West Indies in Jamaica in order to determine factors that could predict survival in this setting. A retrospective study was performed over 11 years from January 1995 to January 2006 examining patients who had EDT at the University Hospital of the West Indies. There were 13 procedures performed over 11 years, with two early survivors (15%) and one patient surviving to discharge. The factors that have been found to be significant predictors of mortality include gunshot injuries, extra-thoracic injury location, inadequate pre-hospital resuscitation, prolonged transportation time and the absence of signs of life on arrival to hospital. Several health care limitations have been uncovered in this setting that must be improved if we are to expect improved outcomes. Focused preparation of the Emergency Room is an initial step that can be easily achieved. We also need to define strict management protocols using selection criteria that are tailored to our local environment in order to exclude futile procedures in unsalvageable patients.

Bile duct injuries in the laparoscopic era: the University Hospital of the West Indies experience / Lesiones de la vía Biliar en la Era Laparoscópica: la Experiencia del HUWI

During the ten-year period July 1994 to June 2004, 20 patients were seen with iatrogenic bile duct injuries. The case notes of these patients were reviewed. Half of the patients were referred after initial surgery at other hospitals. At the University Hospital of the West Indies, bile duct injury rate was 0.8and 1for open and laparoscopic cholecystectomy respectively. Sixty per cent of patients' injuries resulted from open cholecystectomy and the majority of these were during emergency cholecystectomies for acute cholecystitis. A wide range of treatment modalities were employed for patients with minor bile duct injuries but Roux en Y hepaticojejunostomy was the treatment of choice for patients with transection of the common hepatic or bile duct. Follow-up was available in seven of nine patients who had major bile duct injury repair to a median of 36 months and all but one were asymptomatic and had normal liver function tests. There were two deaths because of septic complications.