Acute Acetabular Protrusion: the Hardinge Approach for Implant Removal and One-stage Hip Reconstruction

Acute penetration of a total hip arthroplasty into the pelvic cavity is a grave and potentially catastrophic scenario. Fortunately, this complication is uncommon and rarely encountered during a surgical career. Currently, a two-stage procedure is favoured by most surgeons, but the evidence for this is unconvincing and may expose the patient to unnecessary risks. Furthermore, a two-stage approach may be more suitable for the more common chronic migration of a loose acetabular shell, which fundamentally differs from acute pelvic penetration. We present the case of a 76-year-old man referred to our institution for reconstructive surgery following acute pelvic penetration of the acetabular shell during total hip arthroplasty. We used a single-stage Hardinge approach to retrieve the shell and successfully reconstruct the acetabulum. Specific indications for using this method are proposed. In carefully selected cases of intrapelvic implants, a single-stage method can improve patient outcomes while minimising unnecessary risks associated with the conventional two-stage approach.

Aggressive Resection for a Primary Leiomyosarcoma of the Vena Cava Masquerading as a Pancreatic Head Tumor

Smooth muscle is a normal component of the inferior vena cava (IVC) wall. Although uncommon, the smooth muscle component may undergo neoplastic change. Benign neoplasms are termed leiomyomas, and when there is a malignant change, the nomenclature is changed to an IVC leiomyosarcoma. Leiomyosarcomas of the IVC are rare, with less than 150 cases reported in medical literature. Unfortunately, the majority of IVC leiomyosarcomas are diagnosed at advanced disease stages. Surgical resection of locally advanced lesions is technically challenging, but complete resection is the mainstay of treatment as leiomyosarcomas respond poorly to chemo-radiotherapy. Due to the advanced disease stage at diagnosis and the technical complexity of IVC resection and reconstruction, most patients are transferred to high-volume centers in developed nations. We report a case of a patient with a locally advanced leiomyosarcoma masquerading as a pancreatic head tumor. This patient could not access care in a high-volume center and required aggressive maneuvers to resect the IVC leiomyosarcoma in a resource-poor, low-volume center. We present this case to highlight the steps in operative management and also to show that these procedures can be carried out in resource-poor environments once there is meticulous planning, appropriate equipment, and multidisciplinary care.

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

INTRODUCTION

This retrospective study investigated major adverse limb events (MALE) and mortality outcomes in critical limb-threatening ischemia (CLTI) patients with tissue loss after an endovascular revascularization-first (EVR-1st) strategy.

METHODS

MALE and mortality were assessed in 157 consecutive patients with CLTI and tissue loss from June 2019 to June 2022 at the Eric Williams Medical Sciences Complex, Trinidad and Tobago.

RESULTS

157 patients underwent the EVR-1st strategy, of whom 20 were pivoted to immediate surgical revascularization (SR). Of the remaining 137 patients, successful EVR was achieved in 112, giving a procedural success of 82% and an all-comer overall success of 71%. The mortality and MALE rates were 2.7% and 8.9% at 2 years, respectively. Males and patients with previous major amputations were at significantly higher risk for MALE (p values of 0.016 and 0.018, respectively). There was a statistically significant difference in successful EVR for both Rutherford-Baker (RB) 5 (minor) and RB 6 (major) classifications: 63 (56%) vs. 5 (20%) and 49 (44%) vs. 20 (80%), both with a p value of 0.01. There were no differences in successful EVR amongst Wound, Ischemia, Foot Infection (WIfI) clinical stages. There were no differences in successful EVR amongst the Trans-Atlantic Inter-Society Consensus (TASC II) classifications.

CONCLUSIONS

This study may prove clinically informative and applicable for an EVR-1st management strategy for high-risk patients with CLTI in a limited-resource, Caribbean setting.

TRIAL REGISTRATION NUMBER

NCT05547022 (retrospectively registered).

Necrotizing Fasciitis: Myalgia Is Diagnostic? A Case Series and Literature Review

Necrotizing fasciitis, commonly known as "flesh-eating disease," is an aggressive soft tissue infection that destroys the fascia, subcutaneous tissue, and skin. Specific clinical features (crepitus or radiologic features of gas in tissues) either appear late or are of poor sensitivity. Thus, a high index of clinical suspicion is required for early diagnosis and prompt treatment, which are the best methods of minimizing its high associated morbidity and mortality. We present 3 cases to demonstrate diagnostic difficulties and challenges in management and highlight the feature of pain on muscular activity.

Gender Influence on Abdominal Aortic Aneurysm Surgery in a Caribbean Population

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

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

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

Quality of Life Experienced by Major Lower Extremity Amputees

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.

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

Background

Acute upper limb ischemia is an uncommon clinical manifestation of thromboembolism seen predominantly in patients with atrial fibrillation. Treatment can be by conservative or surgical means but the consensus is that after conservative treatment, symptoms still persist. In this series, an attempt was made at limb preservation and return to functional capacity by early surgery in all patients diagnosed with acute limb ischemia.

Methods

Patients referred with upper limb ischemia (22) were stratified into non-acute (6) treated with anticoagulation alone and those with acute ischemia. Sixteen (16) patients, age range 30–92 years (median 62.4 years) comprising mainly females (13), had clinical evidence of severe ischemia and underwent immediate brachial embolectomy with postoperative anticoagulation.

Results

Sixteen patients underwent 20 embolectomies with immediate reperfusion of limbs and relief of symptoms. Two patients had two re-operations each due to recurrent symptoms but both recovered with good outcome, one going on to have an axillary-radial bypass. There was no limb disability nor limb loss, but one postoperative mortality. All other patients were seen at their 1-year review and at 5 years, eleven out of 15 patients were still alive with most resuming an active lifestyle and some returning to work.

Conclusion

Good outcomes were obtained in this series in both the short and long term. Despite one mortality, there was no limb loss nor disability in a mainly elderly population. Prompt surgery and meticulous long-term anticoagulation reduced complications and improved limb salvage rates ensuring that patients had a good quality of life after surgery.

Major Lower Limb Amputations: Recognizing Pitfalls

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.

Rat Bites in the Diabetic Foot: Clinical Clues

BACKGROUND

Ulcers in patients with diabetic neuropathy in their feet are quite common but should be differentiated from the distinctive but rare ulceration resulting from rat bites in these insensate feet. We describe and analyze the features of rat bites in 2 patients with diabetic neuropathy in their feet and highlight 8 clinical features that should raise suspicion and alert the clinician to this possibility.

METHODS

We describe and analyze the features of rat bites in 2 patients with diabetic neuropathy in their feet and highlight the distinctive clinical features of this condition.

RESULTS

The following features were noted: 1) blood on bed sheets on waking; 2) painless, nonsuppurating ulceration; 3) multiple ulcers that are linear, sharp, or with serrated edges; 4) varying depths within the ulcer; 5) sudden onset (was not noted the day before but found in morning); 6) ulcers not contiguous; 7) often bilateral; and 8) the sole of the foot is not involved. Early recognition and prompt treatment resulted in digit and limb salvage.

CONCLUSIONS

We describe and analyze the features of rat bites in 2 patients with diabetic neuropathy in their feet and highlight 8 clinical features that should raise suspicion and alert the clinician to this possibility.

A rare case of massive lower gastrointestinal bleeding from a ruptured splenic artery aneurysm

Splenic artery aneurysms (SAAs) are an extremely rare cause of asymptomatic massive lower gastrointestinal bleeding with less than a handful of patients surviving such a presentation. A 24-year-old female presented in shock after multiple episodes of massive rectal bleeding. Imaging revealed a heterogeneous mass arising from the tail of the pancreas eroding into the splenic flexure of the colon. Further episodes of bleeding led to an exploratory laparotomy. Intraoperatively, a suspected neoplastic process arising from the tail of the pancreas with contiguous involvement of the splenic flexure of the colon and the greater curvature of the stomach was noted. Distal pancreaticosplenectomy, gastric wedge resection with segmental colectomy and primary anastomosis were performed. Histology revealed a SAA with rupture into the colon. This case report shows that en-bloc resection of a ruptured SAA can be performed with success in the emergency setting.

Clinicopathology and treatment of a giant malignant phyllodes tumor of the breast: A case report and literature review

INTRODUCTION

Phyllodes tumors (PTs) of the breast are extremely rare accounting for less than 1% of all breast tumors globally. Case records at the Trinidad and Tobago Cancer Registry show that only 0.003% of the reported breast cancer cases between 1995 and 2009 were PTs.

PRESENTATION OF THE CASE

We report a 45-year-old woman who presented with swelling of the left breast. Ultrasound, mammogram and computed tomography imaging confirmed the presence of a mass in the right upper inner quadrant of the left breast. A biopsy revealed features supportive of a benign phyllodes tumor. A wide local excision was performed with the removal of a 19×11×10cm mass. Histopathological analysis revealed features consistent with malignant phyllodes tumor. A complete mastectomy of the left breast was subsequently performed. Follow up over a 5-year period did not reveal any evidence of local recurrence or residual disease. To the best of our knowledge, this is the first case report of a malignant PT from the Caribbean and Latin America.

DISCUSSION

Phyllodes tumors are classified as benign, borderline, or malignant based on histologic features including presence of a clear margin, cellularity, stromal overgrowth, tumor necrosis and mitotic index. The clinical challenge is to assess the risk of local tumor and metastatic recurrence in the context of fluid classifications.

CONCLUSION

Our case management approach shows that for patients with malignant PT, a thorough preoperative workup regimen followed by appropriate surgical intervention can result in a desirable prognosis.

Pelvic exenteration case series: A single surgeon's experience at one institution in Trinidad and Tobago

INTRODUCTION

Pelvic exenteration (PE) is an ultra-radical surgical procedure characterized by the en bloc resection of the pelvic organs.

METHODS

In this case series, we report retrospectively on four patients who underwent PE in Trinidad and Tobago from 2012 to 2016. One male patient had rectal cancer while one each of three women had cervical, colon, or rectal cancer.

RESULTS

Early postoperative complications (≤30days) occurred in all patients, while late complications (>30days) occurred in one patient (Grade 1 - Clavien-Dindo classification). Disease recurrence occurred in 50% of patients, and the median overall survival was 8 months (range, 4-15 months).

DISCUSSION

There are many inherent challenges to conducting such major procedures in developing countries, including inadequate blood product supplies, intensive care unit beds, and pre- and post-operative support services. With increased surgical capacity and support infrastructure, hospitals in these regions would be equipped to perform PEs with better outcomes.

CONCLUSION

This case series adds to existing data on the feasibility of performing PE in developing countries. We demonstrate that PE can be performed without major postoperative complications in a resource-limited hospital. To the best of our knowledge, this is the first case series that describes PE in the Caribbean.

A case of distal extrahepatic cholangiocarcinoma with two positive resection margins

Cholangiocarcinoma is an uncommon primary malignancy of the biliary tract that is challenging to diagnose and treat effectively due to its relatively silent and late clinical presentation. The present study reports a case of a 60-year-old male with distal extrahepatic cholangiocarcinoma with a 3-week history of painless obstructive jaundice symptoms and subjective weight loss. Imaging revealed an obstructing lesion in the common bile duct, just distal to the entrance of the cystic duct. Pathology revealed moderately differentiated cholangiocarcinoma with two positive proximal resection margins. The two positive resection margins presented a challenge during surgery and points to an urgent need for further studies to better illuminate diagnostic and therapeutic options for patients with similar clinicopathological presentation.

Rare nodular malignant melanoma of the heel in the Caribbean: A case report

INTRODUCTION

Malignant melanoma of the heel is a rare melanoma subtype with incidence rates that reflect the complex relationship between sun exposure at certain geographic locations, individual melanin levels and overall melanoma risk. It is oftentimes characterized by poor prognosis because of delays in presentation resulting in longitudinal tumor invasion, lymph node involvement and metastasis.

PRESENTATION OF CASE

A 59-year-old woman was admitted to the Eric Williams Medical Sciences Complex, Trinidad and Tobago with a 5mm pruritic lesion on her left heel. At presentation, the lesion was asymmetric with border irregularities, color heterogeneity, with dynamics in elevation and overall size. She was subsequently diagnosed with malignant melanoma with left inguinal lymphadenopathy. A single stage wide local excision (WLE) of the left heel lesion with a split-thickness skin graft (STSG) and a left inguinal lymphadenectomy were performed. Dacarbazine (Bayer) was administered post operatively.

DISCUSSION

Globally, the incidence of malignant melanoma is rapidly increasing, particularly, in countries like Trinidad and Tobago with a significant population of non-fair skinned individuals. There is need for strategic initiatives to increase patient adherence in these populations.

CONCLUSION

The rarity of malignant heel melanomas heightens the need for increased patient awareness and greater clinical surveillance to ensure early diagnosis and treatment.

Successful Example of How to Implement and Develop a Deceased Organ Donation System in the Caribbean Region: Five-Year Experience of the SEUSA Program in Trinidad and Tobago

BACKGROUND

The SEUSA program, the Donation and Transplantation Institute foundation consultancy program, was implemented in Trinidad and Tobago (T&T) in 2010 with the support of the National Organ Transplant Unit (NOTU) and the Ministry of Health of T&T.

METHODS

The SEUSA program included (1) diagnosis of the current situation using the ODDS (Organ Donation Diagnostic Surveys); (2) creation of a human resources structure through Transplant Procurement Management (TPM); (3) detection of all brain and cardiac deaths in the hospitals implementing the DAS (Decease Alert System); (4) in-hospital awareness based on the EODS (Essentials in Organ Donation); and (5) external hospital audits. Additionally continued monitoring is performed.

RESULTS

Thus far, thanks to implementation of the SEUSA program in Trinidad and Tobago 175, healthcare professionals have been exposed to training programs in the organ donation field. The Living Kidney Program was reinforced and the structure of the Deceased Donation (DD) network was defined. Since 2010, 485 potential organ donors have been detected, and 9 have become actual organ donors; 74 patients have received a kidney transplant (59 from living and 15 from deceased donors).

CONCLUSIONS

This project results demonstrate that the application of the SEUSA program is an efficient methodology to develop DD programs that increase and consolidate transplant programs in the Caribbean region.

Brachial artery injury accompanying closed elbow dislocations

INTRODUCTION

Brachial artery injuries from elbow dislocations are uncommon, but they may lead to disastrous consequences if the diagnosis is delayed.

PRESENTATION OF CASE

We report a case of a patient who sustained a fall onto the elbow, with dislocation and brachial artery injury, despite an ipsilateral radial pulse being palpable.

DISCUSSION

Clinicians should maintain a high index of suspicion for brachial injury when patients present with a fall onto the elbow coupled with signs suggestive of fracture-dislocation, nerve injury and/or signs of limb ischemia. Frank ischamia, however, is uncommon as there is a rich collateral anastomosis in the upper limb.

CONCLUSION

A high index of suspicion should be maintained in order to make the diagnosis early. Exploration with excision of the injured segment and reverse vein interposition grafting is the treatment of choice in these cases.

Isolated endometriosis causing sigmoid colon obstruction: A case report

INTRODUCTION

Isolated endometriosis of the intestine causing large bowel obstruction is rare.

PRESENTATION OF CASE

We present a case of endometriosis presenting as large bowel obstruction in a woman of childbearing age. She had no previous symptoms to suggest endometriosis and on presentation urgent surgery was required. The diagnosis of endometriosis was made only after pathological evaluation of the specimen.

DISCUSSION

No cases of endometriosis confined to this sigmoid colon without pelvic involvement were noted in the literature.

CONCLUSION

The diagnosis of endometriosis should be entertained when women of childbearing age presents with large bowel obstruction, whether or not the patient has other evidence of the disease.

Laparoscopic resection of a retroperitoneal myolipoma presenting in a right inguinal hernia

INTRODUCTION

Myolipoma of soft tissue is an extremely rare benign lipomatous lesion. The lesions are most commonly located in the abdominal cavity, retroperitoneum, and inguinal areas. Despite their large size, myolipomas are cured by surgical resection.

PRESENTATION OF CASE

We present the case of a 79 year-old man who presented with bilateral reducible inguinal hernias (right larger than left). After reducing the right inguinal hernia (RIH), the sensation of a palpable mass was noted in the right iliac fossa. CT scan suggested the content of the right inguinal hernia (RIH) to be small bowel mesentery and no other mass was noted in the right iliac fossa (possibly missed on CT scan).

DISCUSSION

A very large 1.8kg retroperitoneal lipomatous lesion, measuring 22cm×16cm×8cm, attached to the right spermatic cord was found and excised laparoscopically during a trans-abdominal pre-peritoneal (TAPP) approach to repair the hernias. The lesion was pathologically defined as a myolipoma.

CONCLUSION

The laparoscopic TAPP approach to repair inguinal hernias allows the surgeon to inspect the peritoneal cavity, and in this case it was possible to safely dissect and remove a large, lipomatous, retroperitoneal lesion laparoscopically. To the best of our knowledge, there are no reports of local recurrence, metastatic disease, or malignant transformation of myolipomas, and the laparoscopic approach to resect such a lesion has not been reported.

Extrauterine leiomyomata presenting with sepsis requiring hemicolectomy

Extrauterine leiomyomas are rare, benign, and may arise in any anatomic sites. Their unusual growth pattern may even mimic malignancy and can result in a clinical dilemma. Occasionally, uterine leiomyomas become adherent to surrounding structures. They also develop an auxiliary blood supply, and lose their original attachment to the uterus, thus becoming 'parasitic'. Parasitic myomas may also be iatrogenically created after uterine fibroid surgery, particularly if morcellation is used. This report presented two cases of parasitic myomas with sepsis, both requiring right hemicolectomy. It reviewed the pertinent literature.

Laparoscopic management of a massive splenic cyst

Splenic cysts are relatively uncommon entities in surgical practice and treatment options vary. We present a case of a young adult woman who presented with a left-sided abdominal mass. A large splenic cyst was diagnosed by abdominal ultrasound and computed tomography. Laparoscopic partial excision with marsupialisation was performed with uneventful recovery and minimal blood loss. Histopathology revealed an epidermoid cyst of the spleen. This report describes the case, and includes a short review of the literature. Laparoscopic partial excision with marsupialisation is a safe and appropriate method of treatment for large splenic cysts.

Malrotation of the midgut in laparoscopic Roux-en-Y gastric bypass

OBJECTIVE

To investigate the strategy of malrotation of the midgut encountered during laparoscopic gastrointestinal surgery.

METHODS

A 37 year old morbidly obese male (body weight=140 kg, BMI>65), presented with complaints of severe lower back pain and significant sleep apnea. After thorough pre-operative assessment, the patient was scheduled for a LRYGB procedure. Malrotation of midgut was found accidentally during the procedure. Besides scheduled LRYGB procedure, an incidental laparoscopic appendectomy was performed and Ladd bands were left intact.

RESULTS

The procedure was performed successfully. The total operative time was 3 hours and 10 minutes and the estimated blood loss was minimal. The patient had an uneventful post-operative recovery, an acceptable body weight loss and no longer complains of back pains or sleep apnea.

CONCLUSION

Laparoscopic surgeons need to be mindful of the possibility of such anomalies during gastrointestinal surgery. LRYGB can be safely performed in patients with intestinal rotation disorders. Routine appendectomy should be considered as a useful addition to LRYGB in these patients.

Laparoscopic cholecystectomy: analysis of 619 consecutive cases in a Caribbean setting

INTRODUCTION

Laparoscopic cholecystectomy has become the gold standard in the definitive treatment of symptomatic gall bladder disease. It boasts superior morbidity and mortality and lower complication rates than open approaches.

AIM

This study outlines the experiences associated with 619 laparoscopic cholecystectomies performed in Trinidad.

METHODS

The records of 619 consecutive patients who underwent the procedure were reviewed. All cases were either performed or supervised by the senior author. The population comprised 511 females and 108 males. The average age was 48.5 years.

RESULTS

The commonest indications for surgery were symptomatic cholelithiasis (380 cases) and acute cholecystitis (111 cases). The mean operating time was 34 minutes. The mean length of stay on the ward was 17.45 hours. Mortality was zero. Only 4 cases were converted to open procedures. The commonest postoperative complication was wound-infection.

CONCLUSION

In summary, this study demonstrates that laparoscopic cholecystectomy can be performed safely in a Third World setting with results comparable to those internationally.

Laparoscopic cholecystectomy in sickle cell disease patients: does operating time matter?

OBJECTIVES

To report the experience of performing laparoscopic cholecystectomy (LC) in patients suffering from sickle cell disease (SCD), and to assess if their postoperative complications can be minimized by shortening the operating time.

METHODS

Strict measures were taken to minimize the operating times and duration of pneumoperitoneum in SCD patients undergoing LC. Data collected included demographics, preoperative haemoglobin, the surgical technique used, operating times, insufflation pressures, perioperative complications and hospital length of stay.

RESULTS

In the 5-year period from July 2003 to June 2008, 19 patients with SCD underwent elective LC. Of these, 84% were female. The mean age was 21.5 years. The most common indication for surgery was symptomatic cholelithiasis (60%). The mean preoperative haemoglobin was 8.2g/dL. No preoperative blood transfusions were given. Four patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP). Mean operating time was 27.9 min (range 20-45 min) which is 2.5-6 times quicker than most reports in the literature. There was no conversion to open surgery. Mean hospital length of stay was 2.5 days. Postoperative complications were noted in four patients with painful crises accounting for 50%. There was no mortality.

CONCLUSION

The study suggests that if stringent measures are taken to shorten the operating time, LC can be safely and effectively performed in SCD patients with minimal perioperative complications.