Penetrating Injury to the great vessels: case reviews and management approaches for West Indian Surgeons

Penetrating injury to the great vessels in the thorax is an increasingly common and alarming clinical scenario in the West Indies, and in Jamaica in particular. The management of these often life-threatening injuries involves careful surgical planning and prompt operation, with close adherence to the principles of adequate pre-operative stabilization and investigations, and intra-operative exposure and repair. While this may be more easily accomplished in tertiary care centres, the geographical realities of the West Indies require that every surgeon be familiar with these techniques. A report of the management of some recent cases is followed by a review of the subject and recommended treatment strategies are outlined.

Childhood portal hypertension in Jamaica

Portal hypertension and bleeding from oesophageal varices in children remain a difficult medical problem. The clinical course and management of children with portal hypertension seen over a 14-year period was reviewed. There were 5 females and 2 males with a mean age of 3.6 years at presentation. Five patients presented with severe upper gastrointestinal bleeding and two with severe hypersplenism. All patients had extra-hepatic portal hypertension. Five patients were treated with endoscopic sclerotherapy, including one who had bleeding five years post-splenectomy. A mean of 9 sclerotherapy sessions was performed in each patient. Complete obliteration of varices was not achived in any patient and a single rebleeding episode occurred in four. Three children underwent operative management consisting of splenectomy in two and splenectomy and central spleno-renal shunt in one. There was no mortality in either group after a mean follow-up of 4.3 years. Sclerotherapy may not be totally successful in long-term management of childhood portal hypertension. Surgical therapy or a combination of sclerotherapy and surgery may be the best approach