Management of obstetric anal sphincter injuries at the University Hospital of the West Indies / Tratamiento de las lesiones obstétricas del esfínter anal en el Hospital Universitario de West Indies

Up to 6% of women sustain severe perineal lacerations that involve the anal sphincters during vaginal delivery. When they occur, obstetric anal sphincter injuries (OASI) may be accompanied by significant morbidity. Therefore, it is important to detect these injuries promptly and for experienced staff to perform sound repair. This report retrospectively assesses a series of seven women with OASI who were managed at a tertiary level hospital in Jamaica over a period of 28 months. Unfavourable details of management that may have adversely affected outcomes were sought from the various cases treated. The incidence of OASI was low (0.2%). There were five third degree and two fourth degree lacerations. After these injuries were repaired, three patients (43%) experienced morbidity such as chronic pelvic pain (43%), anal incontinence (29%), dyspareunia (23%) and recto-vaginal fistulae (14%). In order to improve the outcomes at this institution, several aspects of current care can be improved. Operative repair of these injuries should be delayed until senior staff is available to supervise OASI repair. Both methods of sphincter repair are reasonable options but the use of rapidly absorbable sutures is not appropriate. Finally, prophylaxis against wound infections can be achieved by administering a single dose of intravenous second or third generation cephalosporin at the time of induction of anaesthesia.

Hasta el 6% de las mujeres sufren desgarramientos perineales severos que involucran los esfínteres anales durante el parto vaginal. Cuando ocurren, las lesiones obstétricas del esfínter anal (OASI) pueden estar acompañadas por morbilidad significativa. Por consiguiente, es importante descubrir estas lesiones rápidamente, para que el personal experimentado lleve a cabo una buena reparación quirúrgica. Este informe evalúa retrospectivamente una serie de siete mujeres con OASI, tratadas en un hospital de nivel terciario en Jamaica, durante un periodo de 28 meses. Se buscaron detalles desfavorables del tratamiento que puedan haber afectado adversamente la evolución clínica de los varios casos tratados. La incidencia de las OASI fue baja (0.2%). Hubo cinco desgarramientos de tercer grado y dos laceraciones de cuarto grado. Después de que estas lesiones fueron reparadas, tres pacientes (43%) experimentaron morbilidad, tal como dolor pélvico crónico (43%), incontinencia anal (29%), dispareunia (23%) y fístulas recto-vaginales (14%). A fin de mejorar los resultados clínicos en esta institución, pueden mejorarse varios aspectos del cuidado actual. La reparación operativa de estas lesiones debe retardarse hasta que esté disponible un personal de experiencia para supervisar la reparación de la OASI. Ambos métodos de reparación del esfínter constituyen opciones razonables, pero el uso de suturas rápidamente absorbibles no es apropiado. Finalmente, puede lograrse la profiláxis contra las infecciones de las heridas, administrando una sola dosis de cefalosporina intravenosa de segunda o tercera generación en el momento de inducción de la anestesia.

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.

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

Improving medical undergraduate trauma education through the Trauma Evaluation and Management programme at Mona

This study examines the potential role of the Trauma Evaluation and Management (TEAM) programme in the undergraduate curriculum for medical students in Jamaica. Thirty-two final year medical students were randomly assigned to two groups of 16. One group (No TEAM) completed two 20-item multiple choice question (MCQ) examinations on trauma resuscitation topics. The second group (TEAM group) completed the first 20-item MCQ. The TEAM manual was then distributed to both groups. After the TEAM programme for both groups, the TEAM group had the second MCQ examination. Unpaired [quot]t[quot] tests were used for in-between group and paired [quot]t[quot ] tests for between group comparisons with p < 0.05 being considered statistically significant. Both groups completed a post-course questionnaire rating five items on a scale of one to five. The No TEAM group showed no difference in mean scores between the 1st and 2nd tests (55.3 in the 1st test to 52.2 in the 2nd test, p = 0.32). The TEAM Group improved their MCQ scores from 53.1 pre-module to 69.4 post-module (p < 0.001). A score of four of five was assigned by 28 students for the statement that the objectives were met, that trauma knowledge was improved and that there was overall satisfaction; by 17 students that clinical trauma skills were improved and 29 students that TEAM should be mandatory in the undergraduate curriculum. The TEAM programme improved trauma knowledge skills among senior medical students in Jamaica. The questionnaire results suggested enthusiasm for the programme and that it be made mandatory in the senior undergraduate medical curriculum

Multiple endocrine neoplasia type 2B. A case report and review of the syndrome

This paper presents a case of the very rare multiple endocrine neoplasia Type 2B syndrome. It highlights that because of the presence of superficial neuromas in this condition, there is the possibility for early diagnosis. Recent knowledge of the molecular genetics of this syndrome and the ability to screen family members is also stressed since early thyroidectomy is now recommended to prevent the development of thyroid carcinoma which is the main determinant of prognosis

Pancreatitis and duodenal obstruction following abdominal aortic aneurysm repair

This paper reports one case of pancreatitis and duodenal obstruction that occurred following repair of an abdominal aortic aneurysm. The patient had neither antecedent biliary or pancreatic disease nor alcohol abuse. The presentation was mild and the patient had an uneventful recovery without surgery. We present this uncommon entity and review the available literature.

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.

Granulomatous lobular mastitis. A case report and review of the literature

Granulomatous lobular mastitis is a rare, benign, inflammatory breast condition of unknown aetiology that can clinically mimic breast cancer. Awareness of this condition is important, as the appropriate specimens must be taken to confirm the diagnosis and to rule out an infectious aetiology. While surgical excision has been the traditional therapeutic modality, the most appropriate therapy seems to involve the use of corticosteroids, even in the case of recurrence.

Management of hepatic cysts by percutaneous drainage and instillation of tetracycline hydrochloride

This paper reports two cases of benign hepatic cysts successfully treated by the instillation of tetracycline hydrochloride. The patients presented with solitary large symptomatic hepatic cysts and underwent ultrasound guided needle aspiration followed by the instillation of tetracycline hydrochloride. The cyst size diminished without complication and the patients have remained symptom free. We review the treatment of this uncommon entity and propose that injection of tetracycline hydrochloride is an effective nonoperative treatment of symptomatic solitary hepatic cysts.