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.

A comparison of open and laparoscopic cholecystectomy done by a surgeon in training / Comparación de Colecistectomías abiertas y laparoscópicas realizadas por un cirujano durante su adiestramiento

Laparoscopic cholecystectomy has virtually replaced conventional open cholecystectomy as the gold standard for symptomatic cholelithiasis. The laparoscopic approach brings numerous advantages at the expense of higher complication rates, especially in training facilities. This comparative 18-month review examines the outcomes of 52 cholecystectomies performed by a single surgical resident at the University Hospital of the West Indies--a teaching hospital in Jamaica. The advantages of laparoscopic cholecystectomy have been demonstrated and it has been found to be safe and effective in this training facility.

La colecistectomía laparoscópica ha reemplazado virtualmente la colecistectomía abierta convencional, siendo ahora la norma de oro para la colelitiasis sintomática. El abordaje laparoscópico trae consigo numerosas ventajas a expensas de tasas de complicación más altas, sobre todo en las instalaciones de adiestramiento. Este estudio comparativo realizado a lo largo 18 meses, examina los resultados de 52 colecistectomías realizadas por un residente de cirugía del Hospital Universitario de West Indies – un hospital docente de Jamaica. Las ventajas de la colecistectomía laparoscópica han quedado demostradas, y el tratamiento ha probado ser seguro y efectivo en esta instalación docente.

Laparoscopic cholecystectomy for chronic cholecystitis in Jamaican patients with sickle cell disease: preliminary experience / Colecistectomía laparoscópica para la colecistitis crónica en pacientes jamaicanos con anemia falciforme: una experiencia preliminar

Laparoscopic cholecystectomy, with its advantages of reduced postoperative pain and shorter hospitalization is the accepted standard of care for patients with symptomatic cholelithiasis. A retrospective study was done to assess the outcome of laparoscopic cholecystectomy in patients with sickle cell disease, a group known for its high postoperative morbidity. The study sample comprised of patients seen at the University Hospital of the West Indies during the period 1999 to 2004. Twelve patients were females and four were males. Their mean age was 28.5 years (range 13-43 years). Fifteen underwent elective cholecystectomy for recurrent episodes of cholecystitis while one patient required an emergency procedure. All patients underwent endoscopic retrograde cholangiopancreatography, which successfully removed common bile duct stones which were present in 25of the cases. There were four conversions to open cholecystectomy as a result of obscure anatomy due to scarring and adhesions. The duration of surgery ranged from 70-150 minutes. Six patients developed postoperative complications, four of whom had acute chest syndrome. This resulted in death in one patient. The mean postoperative hospitalization period was 5.5 days. This report indicates that patients with sickle cell disease remain a high risk group with the potential for significant morbidity even when subjected to minimal access surgery.

La colecistectomía laparoscópica, que tiene como ventajas la reducción del dolor postoperatorio y del tiempo de hospitalización, es ahora la norma aceptada en la atención a pacientes con colelitiasis sintomática. Se realizó un estudio retrospectivo a fin de evaluar el resultado clínico de la colecistectomía laparoscópica en pacientes que padecen la enfermedad de células falciformes – un grupo caracterizado por una alta morbilidad postoperatoria. La muestra para el estudio comprendía pacientes atendidos en el Hospital Universitario de West Indies durante el período de 1999 a 2004. Doce pacientes fueron hembras y cuatro varones. Su edad media fue de 28.5 años (rango 13-43 años). Quince fueron sometidos a una colecistectomía electiva debido a episodios recurrentes, en tanto que un paciente requirió un procedimiento de emergencia. A todos los pacientes se les practicó una colangiopancreatografía retrógrada endoscópica, eliminándose así con éxito piedras comunes en el conducto biliar presentes en el 25% de los casos. Hubo cuatro conversiones a la colecistectomía abierta, como resultado de una anatomía oscura debido a cicatrizaciones y adhesiones. El tiempo de duración de la cirugía fluctuó de 70 a 150 minutos. Seis pacientes desarrollaron complicaciones postoperatorias, cuatro de ellos con síndrome torácico agudo. Como resultado de ello se produjo la muerte de un paciente. El período postoperatorio medio fue de 5.5 días. Este reporte indica que los pacientes con anemia falciforme continúan siendo un grupo de alto riesgo, con un potencial de morbilidad significativo, incluso cuando son sometidos a cirugía de mínimo acceso.

Endoscopic retrograde cholangiopancreatography use at the University Hospital of the West Indies

All patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) at the University Hospital of the West Indies (UHWI) were entered into a prospective database. Parameters included demographics, indication for the procedure, success of the ERCP and any immediate complications noted. Retrospectively, the patients' case notes were analyzed for complications developing after 24 hours, and outcome. During the period March 1999 to December 2002, a total of 120 consecutive patients were subjected to 123 ERCPs, all being performed by a single gastroenterologist. Of these 120 patients, eight had ERCP as outpatients and were transferred back to their referring hospitals. These patients were excluded from further analysis. Of the 115 UHWI patients, the case notes of 96 were available for analysis and this group formed the basis of this review. ERCP had successful cannulation in 95 of patients. There were 70 females and 26 males with a female to male ratio of 2.7:1. Age ranged from 13 to 85 years (mean +/- SD, 43 +/- 17), males being an average six years older than females. The most common indication for ERCP was a patient with cholelithiasis and abnormal liver function tests scheduled for laparoscopic cholecystectomy. This made up 33 of patients and in this subgroup, sickle cell disease accounted for 50 of cases. Patients with common bile duct stones preoperatively and post-cholecystectomy accounted for 13 and 17 respectively while gallstones pancreatitis accounted for 13 of cases, including three patients with severe pancreatitis. While 64 of the patients had normal cholangiogram, 66 of them had sphincterotomy. Common bile duct stones were seen in 23 cases and complete removal was successful in 48. There were ten cases (10) of ERCP pancreatitis and this was severe in three patients and the direct cause of death in one. One patient had ascending cholangitis post ERCP and there were no cases of post-sphincterotomy bleeding or duodenal perforation. Endoscopic retrograde cholangiopancreatography at the UHWI has high diagnostic yield but its therapeutic use needs further development

A case of pulmonary lymphangioleiomyomatosis

A case of pulmonary lymphangioleiomyomatosis (PLAM) occurring in a 48-year-old Jamaican female is presented. The clinical, radiological, and pathological findings are typical of this rare condition, and serve to emphasize the need for a high index of suspicion in order to make the diagnosis and commence therapy early in the course of the disease. The outlook for patients with PLAM continues to be poor

Thymic surgery in Jamaica 1992-2000

The treatment for thymic tumours and/or myaesthenia gravis (MG) includes thymectomy. Controversy exists as to the optimal timing and operative approach to thymectomy. At the University Hospital of the West Indies, Kingston, Jamaica, the results of thymic surgery during the period 1992 to 2000 were studied retrospectively. There were 26 patients operated on, 17 females and nine males. Twenty-three underwent thymectomy to treat MG, and three to remove a thymoma. The average age for females was 30.7 years, and 25.1 years for males. Average duration of symptoms prior to surgery was 16 months (all patients), and the interval between diagnosis and referral averaged 2.6 months. All patients underwent thymectomy via median sternotomy with a cervical extension of the incision if required. A policy of phrenic nerve preservation, even if residual tumour was left behind, was followed. Patients with thymomas were given post-operative radiotherapy. Chemotherapy was not given to any patient. The medium and long term results of thymic surgery in a developing country are presented. The results are within international norms, although the small patient population makes statistical analysis difficult. There appears to be no need to change current practice, despite the reported efficacy of less invasive approaches to thymic surgery

Potential role for advanced trauma life support programme in improving trauma care in Jamaica

Data from the Road Safety Unit in the Ministry of Transport and Works, Jamaica, show an increase in road traffic accidents from 7861 in 1991 to 11,010 in 1999. The average number of deaths annually was 380 +/- 48 (SD) while injuries averaged 3320 +/- 262 per year. This represents an injury to death ratio of 8.7 compared with 24.9 for Trinidad and Tobago and 40 for Canada. During the period 1991 to 2000, an average of 796 +/- 159 (SD) murders were committed annually. The number of murders increased by over 280 per cent between the decade of the seventies and the nineties. Data from the trauma registry of the University Hospital of the West Indies showed that 29.6 per cent of all admissions to the surgical ward between January 1998 and December 31, 2000, were due to injuries. There were 97 deaths (3) during this period and 33 occurred in the Accident and Emergency Department with 70 per cent occurring within 120 minutes of their arrival. The Advanced Trauma Life Support (ATLS) Programme emphasizes the resuscitation and stabilization of injured patients in the first few hours after injury. Most Emergency Departments in Jamaica are staffed by relatively junior medical officers and the low injury to death ratio among victims of motor vehicle accidents may be due to suboptimal care. Introduction of an ATLS programme in Jamaica may reduce the number of preventable deaths and also stimulate interest in trauma care thus increasing preventative measures to decrease the high incidence of trauma in Jamaica

Compartment syndrome of the thigh. A case report and review of the literature

A case of compartment syndrome of the thigh following a gunshot injury that resulted in significant morbidity is presented. Early diagnosis of this uncommon condition requires a high index of suspicion in order to reduce morbidity and mortality. Timely diagnosis, emergency three-compartment decompression, prophylaxis against reperfusion syndrome and aggressive rehabilitation are necessary for a favourable outcome.

Colonic lipomas at the University Hospital of the West Indies

Lipomas of the colon are uncommon but cause diagnostic difficulty when they are symptomatic. The clinical and pathological features of 17 cases of colonic lipomas diagnosed at the University Hospital of the West Indies between 1970 and 1999 are reported. Ten cases were symptomatic, two of these being diagnosed with adult intussusception. Six patients had incidental lipomas in bowel resected for other pathology while one lipoma was diagnosed on sigmoidoscopy. Increased awareness of these lesions will enhance pre-operative diagnostic accuracy.

Trauma aetiology and cost in the Accident and Emergency Unit of the University Hospital of the West Indies

Trauma accounted for 37of 22,311 patients seen in the Accident and Emergency Unit (A&E Unit) at the University Hospital of the West Indies (UHWI) during 1996. Thirty-nine per cent of injuries were intentional and 18were due to motor vehicle accidents. Knives, machetes and rocks accounted for 75of the injuries compared with 5for gunshot wounds. Passengers were injured in about 40of motor vehicle accidents and pedestrians in 19. The admission rate was 16and the orthopaedic clinic received 75of the patients referred to specialist clinics. Victims of motor vehicle accidents made up a greater proportion of admissions (24) than those of intentional violence (13). The average cost of caring for each patient in the A&E unit was US$70 resulting in an annual cost of US$578,000.