Caroli's Disease Associated with a Gastric Diverticulum

Caroli's disease or communicating ectasia of the intrahepatic biliary tree is a rare disease with unknown aetiology. The coexistence of this along with the uncommon condition of a gastric diverticulum has never been reported before. A deficiency in the fibromuscular matrix of both the bile ducts and the gastric wall may explain why these two pathologies may coexist in a single patient. (AU)

Caroli's Disease Associated with a Gastric Diverticulum

Caroli's disease or communicating ectasia of the intrahepatic biliary tree is a rare disease with unknown aetiology. The coexistence of this along with the uncommon condition of a gastric diverticulum has never been reported before. A deficiency in the fibromuscular matrix of both the bile ducts and the gastric wall may explain why these two pathologies may coexist in a single patient.

Thyroid surgery without drainage: 15 years of clinical experience

Drainage in thyroid surgery has been a routine but empirical practice with no scientific evidence to support its benifit. The largest series to date of nondrainage in thyroid surgery is presented, comprising 260 patients over a 15-year perios. No case selection for non-drainage was employed. Two hundred and fifty-nine cases were not drained and included toxic goitres, and bilateral and redo procedures. There was one thyroid storm and two cases of subcantaneous fluid collection, treated by needle aspiration. No cases of recurrent laryngeal nerve injury, airway obstruction or death were recorded. This study strongly demonstrates the safety of non-drainage in routine thyroid surgery (AU)

Routine drainage in thyroid surgery: is this practice obsolete? - abstract

Thyroid surgery without drainage is thought by many surgeons to be a practice with potentially catastrophic consequences. This thinking which evolved from the late nineteenth century view of absolute prescription of thyroidectomy because of bleeding has been questioned in recent papers. Our experience at surgery also led us to doubt the necessity of routine drainage, and so, since 1976, we practised non-drainage prospectively in 248 consecutive thyroidectomies. Subtotal lobectomy was done in 56 cases, unilateral lobectomy in 115 and bilateral subtotal thyroidectomy in 77 cases. This is the largest such series reported to date. In only one case was drainage considered necessary, and the only complication attributable to non-drainage was minor subcutaneous fluid collection (2 cases). In thyroid surgery, following meticulous haemotasis, routine drainage is not necessary (AU)

Intussusception in infancy and childhood

Intussusception is the commonest cause of intestinal obstruction in childhood in Trinidad. A review of 94 consecutive cases seen at the General Hospital, Port-of Spain, over a 12 year period (1974-1985) indicates that there had been a very rapid increase in incidence of intussusception in the last 4 years. The majority were under 1 year of age (87 percent) and there was a predominance in the Negro child (62 percent). Male to female ratio was 1.2:1 . A high misdiagnosis rate (55 percent) lead to inappropriate treatment and delay in surgical intervention. This resulted in a high case fatality (6.4 percent) and complication rate. In order to minimize morbidity and mortality from intussusception steps must be taken to ensure earlier diagnosis and treatment. (AU)

Myocutaneous flaps and the West Indian general surgeon - abstract

Although myocutaneous flaps are not yet widely used in the West Indies, their use has facilitated reconstructive surgery in difficult cases. Because many of our patients present with advanced disease and since multidisciplinary teams are usually unavailable, these reliable flaps could be very valuable. From November 1983 to 1987, we have performed 30 flaps in 29 cases. There were 18 rectus abdominis flaps for primary (9) or recurrent (8) breast cancer, or necrotising fascitis (1); in this group, there was 1 partial (10 percent) loss and 1 total loss of the graft. Seven gastrocnemius grafts were done for tibial non-union (3), osteomyelitis (2) or traumatic soft tissue loss (2); there were 4 latissimus dorsi, and 1 trapezius, grafts. Primary healing was achieved in all the cases except the two abdominal flaps. Unlike the traditionally used tubed-skin flap, the musculo-cutaneous flap can be performed at one operation. The excellent vascularity also helps the graft to withstand radiotherapy and resist infection. Thus, use of a myocutaneous flap permits wide resection of tumour or generous debridement of infected tissue with immediate reconstruction in one stage. Its high success rate, with primary healing, makes it an extremely valuable tool in the armamentarium of the West Indian general surgeon (AU)

Breast cancer in Trinidad - abstract

Breast cancer is one of the commonest malignancies in the Trinidadian woman. A 7-year study of breast biopsies from 2,642 women shows that 20 per cent of the lesions biopsied were malignant. Patients with cancer were from 23 to 92 yrs, with a peak prevalence in the 45-60 yr. age group. The age-specific rate increased steadily with age. Most patients were multiparous; 92 per cent of them had breast-fed their children. Fifty-one per cent had stage 1 disease; 76 per cent had infiltrating duct carcinoma; 7.0 per cent scirrous, 2.7 per cent medullary, 1.6 per cent mucoid and 1.3 per cent Paget's Disease of the nipple; other less common carcinomas accounted for the remainder. The high rates of multiparity and breastfeeding in our patients with breast cancer are unusual associations with this disease. Our high incidence of infiltrating duct carcinoma is consistent with many studies; this type is usually linked to a poor prognosis. Education of the public on breast and its associated epidemiological factors could result in more patients presenting with stage 1 disease (AU)

Behcet's syndrome with unusual manifestations

A patient with two uncommon manifestations of Behcet's Syndrome, oesophageal ulceration, and glomerular disease is presented. In both systems, as in all others affected by Behcet's Syndrome, there was vasculitis principally involving veins, venules, and capillaries. Response to conventional management was not successful. (AU)

The teenager's breast lump: to cut or not to cut? - abstract

The presence of a breast lump, in any age group, raises the possibility of malignancy and, as a result, it has been suggested that all solid descrete lesions in the breast be excised. Since breast masses are quite common in teenage West Indian women and breast carcinoma in this group is very rare, we thouht it necessary to examine this policy to early excision in our population. Of 2,642 consecutive breast biopsies (1976-1982), 658 (24.5 percent) were in teenage girls. All lumps were benign in this age group. Fibroadenoma was the commonest lesion (77.6 percent). For fibroadenoma, clinical diagnostic accuracy was 92 percent; in the 8 percent that were misdiagnosed, the histological findings were always benign. Fourteen per cent of patients with fibroadenoma either had previous excision or returned with recurrences during the study period. An initial conservative policy in our teenagers with clinically benign breast masses will result in minimising the number of operations by: (a) avoiding surgery in most patients with fibroadenosis; (b) performing a single operation in many patients with "recurrent: or multiple fibroadenomas, and (c) avoiding surgery where spontaneous regression of fibroadenomas occurs. Minimising the number of breast operations has clear economic benefits while, in a population prone to hypertrophic scarring and keloids, there are cosmetic advantages. A conservative policy is not likely to increase the risk of missing malignancies because clinical diagnostic accuracy is high in this age group and we have not encountered teenagers with breast carcinoma. Among West Indian teenagers, routine observation of clinically benign breast disease needs to be considered as the management of choice (AU)

Gall bladder disease in Trinidad

In Trinidad, cholecystectomy is now the most common elective intra-abdominal operation performed by the general surgeon. A review of 220 patients shows that gall bladder disease affects our population at a much younger age (average 43.8 years) than that reported for Caucasisans in the United Kingdom, United States and Sweden. The female to male ration (8.6:1) is one of the highest reported. There is no race predisposition to the disease, which is evenly distributed between the two major ethnic groups represented in the population. In this population, first pregnancy at an early age and multiparity seem to be the important factors which predispose the young female to cholelithiasis(AU)

Gall bladder disease in Trinidad

In Trinidad, cholecystectomy is now the most common elective intra-abdominal operation performed by the general surgeon. A review of 220 patients shows that gall bladder disease affects our population at a much younger age (average 43.8 years) than that reported for Caucasians in the United Kingdom, United States and Sweden. The female to male ratio (8.6:1) is one of the highest reported. There is no race predisposition to the disease, which is evenly distributed between the two major ethnic groups represented in the population. In this population, first pregnancy at an early age and multiparity seem to be the important factors which predispose the young female to cholelithiasis.(AU)

Colorectal carcinoma in Trinidad - abstract

Colorectal cancer is the fifth commonest cause of death from malignancies in Trinidad. Data available from the Ministry of Health and the Central Statistical Office in the 10-year period 1969-1978 provided 620 cases for analysis. In addition, 152 confirmed cases from the Port-of-Spain General Hospital were reviewed. The mortality rate for cancer of the colon was 4.4 per 100,000 of population with an increasing trend over the 10-year period. The mortality rate for rectal cancer was 1.8 per 100,000 of population with a decreasing trend. The average age of diagnosis was 64.3 years with rapidly rising incidence with advancing age. The M: F ratios are 1 : 1.05 and 1.1 : 1 for cancer of the colon and rectum respectively. There was a higher incidence in the Black, Chinese and Christian communities and a lower incidence in the East Indian, Hindu and Muslim communities. The Chinese had lesions predominantly on the left and the East Indians on the right side of the colon and in the rectum. The negroes had a more even distribution of the lesions. Only 51.6 percent of the lesions were in the rectum and sigmoid colon and 7.4 percent of the cancers were multiple. A relatively high percentage of Stage IV cases (39 percent) was encountered, with a correspondingly low resectability rate (67 percent) and high incidence of intestinal obstruction (29.9 percent). Fortunately, in the later years of the study, more early cancers and less Stage IV lesions had been diagnosed. The increasing incidence of colon cancer demands that a higher index of suspicion with more liberal use of barium enema and sigmoidoscopic examinations be employed in order to make earlier diagnosis and deliver prompt treatment (AU)

Lower limb amputations in Trinidad: analysis of 576 cases - abstract

Major lower limb amputation remains one of the commonest operations done by the general surgeon and carries the highest mortality of all operations at the Port-of-Spain General Hospital. While vascular insufficiency is the main indication for amputation in Great Britain and the United States, we had a clinical impression that the diabetic septic foot was more important in our population. Of 658 consecutive major limb amputations done at the Port-of-Spain General Hospital from January 1979 to December 1984, 576 case notes were available for analysis. There were 299 males and 277 females with an equal mean age of 63 years. Ages ranged from 27 years; 81 percent of patients were over 60 years, 76 percent were diabetics, 34 percent hypertensive and 28 percent were both diabetic and hypertensive. Seventy-seven per cent had above-knee (A-K) and 23 percent below-knee (B-K) amputations (BK: AK = 0.29) A-K amputees being older (65 years) than B-K amputees (59 years). Of 43 bilateral amputees, 38 were A-K (B-K: A-K = 0.13); 84 percent of bilateral A-K amputees had peripheral vascular disease (PVD). Diabetes mellitus with limb sepsis (55 percent) was the commonest indication for amputation followed by PVD (36 percent). The overall mortality rate was 23 percent, with a higher mean age among fatalities (72.1 yrs). Over whelming sepsis and "multiorgan failure" (54 percent), ischaemic heart disease (76 percent), cerebro-vascular accident (11 percent) and pulmonary embolism (9 percent) were the major causes of death. Mortality among diabetics (23 percent) was not different from among non-diabetics (23 percent), but PVD associated with diabetes (37 percent) had a significantly higher (p < 0.001) rate than PVD without diabetes (14 percent). Consistent with published data, the AKA mortality rate (26 percent) was higher than that for BKA (10 percent) (p0.001). The average hospital stay was 51 days (range of 4 - 190). Diabetics (57 days) stayed longer than non-diabetics (35 days). The high amputation rate, mortality rate and prolonged hospitalisation suggest that urgent measures be taken to improve the outcome for patients with ischaemic or septic feet. We recommend an extensive education programme in foot care for doctors, nurses and diabetic patients, early and aggressive medical and surgical treatment of the infected diabetic foot, that attempts be made to increase ou B-K: A-K ratio more frequent arteriography and vascular reconstruction (AU)

Carcinoma of the penis in the West Indies: a Trinidad study

In the period 1975-1983, 40 cases of histologically proven penile cancers were observed. Although penile cancer is relatively common in the Indians of India and the negro population of our Caribbean neighbour Jamaica, this study shows that it is quite infrequent among both the Indians and negroes living in Trinidad. This is due probably to better socioeconomic conditions in our population (AU)

Splenic flexure volvulus

Splenic flexure volvulus is rare, only 22 cases having been reported. Though these usually present with chronic intermittent clinical features we recently encountered a case presenting as acute intestinal obstruction which, on plain abdominal x-rays, had classical features of this condition.(AU)

Breast disease in young West Indian women: an analysis of 1051 consecutive cases

Our analysis of 1051 breast biopsies in West Indian women under the age of 30 y revealed that 99 percent of the breast lumps were benign. Fibroadenoma was the commonest (67 percent) lesion and there was a steady increase in the frequency of fibrocystic disease with age. Carcinoma in this group is therefore rare. Thus most patients can be reassured with certainty of their benign disease and have biopsy at a convenient time.(AU)