Minimally invasive surgery training in the Caribbean: a survey of general surgical residents and their trainers / Entrenamiento de cirugía mínimamente invasiva en el Caribe: encuesta a los residentes de cirugía general y sus entrenadores

BACKGROUND: There has been debate on the feasibility of incorporating minimally invasive surgery (MIS) into surgical practice in developing countries due to resource and training limitations. Our study establishes the current and desired state of MIS training in surgical residency programmes in the Caribbean. METHODS: An adapted version of a previously administered questionnaire was issued to surgeons and residents involved in the general surgical residency programme of The University of the West Indies in Barbados, Jamaica and Trinidad and Tobago. Data were analysed using the Statistical Package for the Social Sciences, version 17.0. RESULTS: The questionnaire was sent to 41 surgeons and 41 residents with a 65% response rate. Most residents had performed less than 25 basic laparoscopic procedures. Up to 82% of residents felt that they would be unable to perform advanced laparoscopic procedures due to lack of training. The principal negative factors influencing MIS training included lack of operating room time, lack of equipment and lack of preceptor expertise. Both surgeons (83.4%) and residents (93.4%) strongly felt that a surgical skills laboratory would be helpful for the acquisition of MIS skills. Both surgeons (85.7%) and residents (100%) felt that there was a role for an MIS surgeon in fulfilling training obligations. CONCLUSION: The basic and advanced MIS experience of residents in the Caribbean is limited. Surgeon training and resource limitations are major contributing factors. There is a strong desire on the part of surgeons and residents alike for the incorporation of more effective MIS training into the residency programme in the Caribbean.

ANTECEDENTES: Ha habido debates en torno a la factibilidad de incorporar la cirugía mínimamente invasiva (CMI) a la práctica quirúrgica de los países en desarrollo, debido a las limitaciones de recursos y entrenamiento. Este estudio establece cual es el estado actual y el estado deseado en relación con la CMI en los programas de residencia quirúrgica en el Caribe. MÉTODOS: Una versión adaptada de un cuestionario previamente aplicado fue administrada a cirujanos y residentes participantes en el programa de residencia de cirugía general del Hospital Universitario de West Indies en Barbados, Jamaica, y Trinidad y Tobago. Los datos se analizaron usando el Programa estadístico SPSS para ciencias sociales, versión 17.0. RESULTADOS: El cuestionario fue enviado a 41 cirujanos y 41 residentes, y se obtuvo una tasa de respuesta del 65%. La mayor parte de los residentes habían realizado menos de 25 procedimientos laparoscópicos básicos. Hasta un 82% de los residentes, nsentían que no serían capaces de realizar procedimientos laparoscópicos avanzados, debido a la falta de entrenamiento. Los principales factores negativos que afectaban el entrenamiento de la CMI incluían la falta de un horario para usar el salón de operaciones, la falta de equipos, y la falta de preceptores expertos. Tanto los cirujanos (83.4%) como los residentes (93.4%) sentían fuertemente que un laboratorio de habilidades quirúrgicas sería útil para el desarrollo de las habilidades de la CMI. Tanto los cirujanos (85.7%) como los residentes (100%) sentían que el papel de un cirujano debía incluir la obligación de impartir entrenamientos. CONCLUSIÓN: La experiencia básica así como la experiencia avanzada de CMI de los residentes del Caribe es limitada. Las limitaciones en relación con los recursos y el entrenamiento a impartir por los cirujanos, es uno de los factores principales en tal sentido. Por parte de los cirujanos así como de los residentes, existe un fuerte deseo de incorporar entrenamientos más efectivos de CMI al programa de residencia del Caribe.

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.

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.

Clinicopathologic profile of gastric carcinomas at the University Hospital of the West Indies / Perfil clínico-patológico de los carcinomas gástricos en el Hospital Universitario de West Indies

The objective of this study was to examine the clinicopathologic features of gastric cancer seen at the University Hospital of the West Indies (UHWI) and to compare the findings with other studies. A retrospective study was conducted using data obtained from the surgical pathology reports of all gastrectomies and gastric biopsies during the period January 1993 and December 2002. Additional cases were identified from the Department of Surgery's audit database. Demographic, clinical and pathological features were analyzed. Two hundred and sixteen patients were identified, 126 males and 90 females. One hundred and thirty-six underwent biopsy procedures but no definitive surgery aimed at cancer eradication, while 70 had gastrectomy. The peak age prevalence in both males and females was the 70-79-year age group. While the antrum was the commonest site, there was an overall increase in tumours of the gastro-oesophageal junction and tumours of the entire stomach in the latter five-year period of the review especially in the 50-59-year age group. Epigastric pain and constitutional symptoms were the common presenting features, and the most common gross tumour characteristic was an ulcerating mass, while histologically, the intestinal variety was most common. Lymph node metastases were common. Helicobacter pylori (Hpylori) were present in 16.7while chronic multifocal atrophic gastritis was present in 40. This study indicates that the gastric cancer pattern is typical of developing countries. However, the low prevalence of H pylori in the resected specimens may indicate the importance of other risk factors for gastric cancer development in this population. This warrants further study.

El objetivo de este estudio fue examinar los aspectos clínicopatológicos del cáncer gástrico observados en el Hospital Universitario de West Indies, y comparar nuestros hallazgos con los de otros estudios. Se llevó a cabo un estudio retrospectivo usando datos obtenidos de los reportes patológicos quirúrgicos de todas las gastrectomías y biopsias gástricas durante el período de enero de 1993 y diciembre de 2002. Se identificaron casos adicionales de la base de datos de auditoría del Departamento de Cirugía. Se analizaron aspectos demográficos, clínicos y patológicos. Se identificaron doscientos dieciséis pacientes, 126 hombres y 90 mujeres. Ciento treinta y seis fueron sometidos a procedimientos de biopsia, pero no se realizó ninguna cirugía definitiva encaminada a la erradicación del cáncer, en tanto que a setenta se les practicó gastrectomía. La prevalencia de edad pico tanto en hombres como mujeres fue el grupo de 70–79 años. Si bien el antro gástrico fue el sitio más común, hubo un aumento general en tumores de la unión gastroesofágica y tumores de todo el estómago en el último período quinquenal de la revisión especialmente en el grupo de 50–59 años de edad. El dolor epigástrico y los síntomas constitucionales fueron los síntomas más comunes que se presentaron, y la característica más común del tumor macroscópico fue una masa ulcerosa, mientras que histológicamente la variedad intestinal fue más común. Fueron comunes las metástasis del nódulo linfático. Helicobacter pylori (H pylori) estuvieron presentes en el 16.7 %, en tanto que la gastritis crónica atrófica multifocal estuvo presente en el 40%. Este estudio indica que nuestro patrón de cáncer gástrico es típico de los países en vías de desarrollo. Sin embargo, la baja prevalencia de H pylori en nuestros especímenes resecados, pueden ser un índice de la importancia de otros factores de riesgo tales como fumar, el uso consuetudinario del alcohol, o la dieta, en relación con el desarrollo del cáncer en nuestra población. Esto merece un estudio ulterior.

Civilian rectal trauma: the surgical challenge

Using the Department of Surgery, Radiology, Anaesthesia and Intensive Care's operative database and information from the Trauma Registry for patients presenting after 1998, a retrospective study of patients seen between the period 1992 and 2002 was done at the University Hospital of the West Indies with the objective of determining the treatment and outcome of patients with a diagnosis of rectal trauma. Over the 10-year period, 45 patients were seen with this diagnosis. Eighty-two per cent of the cases were males, with a mean age of 29.8 years (range 16-70 years) while the eight female patients had a mean age of 36.8 years. Low velocity gunshot wounds accounted for 64 of the entire group and for 78 in males. Six of the eight cases seen in females were iatrogenic occurring during gynaecological operations. Sixty-three per cent of rectal injuries were associated with other injuries with the genitourinary system most commonly involved The majority (83) were diagnosed preoperatively by visualization of the rectal wound or the presence of blood on proctosigmoidoscopy. All the patients had peri-operative antibiotics and diversion with a proximal sigmoid colostomy. Fifteen per cent of cases had presacral drain insertion. Distal rectal washout was not used. There were no deaths. Seventy-three per cent of patients had closure during the period under review at an average time of 8.5 months after initial surgery. The other 27 after an average of 23 months did not have documented closure. The mainstay of treatment for civilian rectal trauma remains diverting sigmoid loop colostomy, despite its morbidity, and peri-operative antibiotics

Surgical management of perforated duodenal ulcer: the changing scene

To determine the management of perforated duodenal ulcer at the University Hospital of the West Indies (UHWI) in this era of Helicobacter pylori, the medical records of all patients seen at the UHWI during the period July 1997 to June 2002 with an intra-operative diagnosis of perforated peptic ulcer were reviewed The records were analyzed for the following: age, gender, duration of symptoms, non-steroidal anti-inflammatory drug (NSAID) use, smoking status, operative repair duration of hospitalization, Helicobacter pylori status and medical therapy, peri-operative complications, mortality and recurrence. Ninety per cent of the cases were males. All females in whom perforation occurred were age 50 years and older compared to males where 58 of cases presented before age 50 years. Perforations in acute ulcers occurred in 80 of cases. The majority of patients were male smokers. Non-steroidal anti-inflammatory drug use was also an important risk factor in elderly females. Simple surgical closure and standard triple therapy antibiotics to eradicate Helicobacter pylori was the most common treatment offered. Mortality was one per cent and follow-up poor but 11 of patients had documented recurrent peptic ulceration. In this study population, perforated duodenal ulcer occured overwhelmingly in males less than 50 years of age. There is a trend towards exclusive simple surgical closure and H pylori eradication at the UHWI for patients with perforated duodenal ulcer but this needs to be supported by documentation of H pylori prevalence in the population of patients presenting with perforated peptic ulcers

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