A decade of major vascular trauma: Lessons learned from gang and civilian warfare.

INTRODUCTION Trinidad and Tobago is a trans-shipment point for the illegal trade of drugs, arms and ammunition and, as such, has a high incidence of gang-related warfare and drug-related crimes. This has led to a high incidence of gunshot and stab wounds, with associated major vascular injuries. We describe our management strategies learned from a decade of vascular trauma experience. METHODS A retrospective analysis of age, gender, type of trauma, vessel injured, procedure and outcome for all cases of vascular trauma between 2006 and 2015 at two surgical units in Trinidad and Tobago. RESULTS There were 198 vascular trauma cases (232 procedures), involving 159 (80%) males at a mean age of 33 years. Gunshots accounted for 103 (52%) cases, followed by stabs/chops (n=50; 25%) and lacerations (n=15; 8%). The most commonly injured vessels were the radial/ulnar arteries (n=39; 20%) and the superficial femoral artery (n=37; 19%). There were seven pseudoaneurysms and three traumatic arteriovenous fistulae. Repair techniques included primary (n=82; 35%), reversed vein (n=63; 27%), polytetrafluoroethylene (n=58; 25%), oversew (n=24; 10%) and endovascular (n=5; 2%) techniques. There were eight (4%) secondary amputations and eight (4%) deaths. CONCLUSIONS Major vascular trauma causes significant morbidity and mortality in Trinidad and Tobago, with the majority of cases due to gunshot injuries secondary to gang-related warfare and civilian violence. We compare our experience with that in the literature on the epidemiology and management of vascular trauma.

Patterns of arteriosclerotic lesions of the lower extremity in a West Indian population based on angiographic findings and ethnicity.

INTRODUCTION: This study aimed to determine whether ethnic differences show different patterns of arterial disease in the lower limb. METHODS: A prospective analysis of 100 consecutive patients with 160 lower limb arteriograms was performed looking at the pattern of disease with relation to ethnicity in Trinidad and Tobago. RESULTS: There were 53 male and 47 female patients with an age range of 43-90 years (mean: 66 years). Of the 100 patients, 45 were of East Indian descent, 36 of Afro-Caribbean descent, 14 of mixed descent and 5 had other backgrounds. There were 32 smokers and 69 diabetics. The most commonly affected artery in East Indians was the anterior tibial artery (ATA, 70%) followed by the peroneal artery (60%), superficial femoral artery (SFA, 60%), posterior tibial artery (PTA, 57%) and tibioperoneal trunk (TPT, 39%). In Afro-Caribbeans, the most commonly affected artery was the ATA (79%) followed by the PTA (74%), peroneal artery (66%) and TPT (55%). The mixed group showed the PTA (85%) to be most diseased followed by the peroneal artery (75%), ATA (70%), SFA (70%), dorsalis pedis artery (DPA, 60%) and TPT (50%). Overall, the most diseased vessel in all groups was the ATA (73%) followed by the PTA (66%), peroneal artery (64%), SFA (59%), TPT (46%), DPA (38%), popliteal artery (31%) and medial plantar artery (MPA, 29%), with the proximal vessels not being affected severely. CONCLUSIONS: Ethnic divisions were only statistically significant (p<0.05) with East Indians showing worse disease in the profunda femoris artery and Afro-Caribbeans showing worse disease in the PTA, DPA and MPA. This suggests that environmental factors may play a significant role in the disease process including smoking and dietary factors rather than purely genetics.

Penile Carcinoma in Northern Trinidad and Tobago.

OBJECTIVE: To determine the current incidence as well as general and ethnic trends of penile carcinoma in northern Trinidad and Tobago. METHODS: A retrospective analysis was conducted on all cases of penile carcinoma presenting in north and east Trinidad, as well as Tobago over an eight-year period. RESULTS: There were 19 cases from October 2003 to February 2012 with an age range of 42-96 years, mean of 59 years; peak age of presentation was 41-50 years and the number of cases presenting per year varied from one to four, with an average of three new cases yearly. Of 19 cases, 63% (12) originated from Port-of-Spain General Hospital (POSGH), 26% (5) from Sangre Grande (SGH) and 11% (2) from Tobago (TRH). There were 14 (74%) patients of African descent, three mixed and two of East Indian descent. There were four associated inflammatory lesions, five with ulcers, five verrucous lesions and two (10.5%) with human papillomavirus (HPV). One case presented with metastatic disease to the groin with erosion into the common femoral artery resulting in a blow-out of the vessel. The patient had the vessel oversewn and an extra-anatomic bypass done. He later had an above-knee amputation due to graft infection and failure. CONCLUSION: The incidence of penile carcinoma in north Trinidad and in Tobago is low and has halved in the past two decades. It stands at 0.6 cases per 100 000 males with the peak age group being 41-50 years, and with 95% of cases occurring between 41 and 80 years. There is a statistically significant association with active infection and being Afro-Caribbean. The decreasing incidence may be attributed to better hygiene, a higher rate of circumcision and low HPV rates in our population.

The slipping slipper sign: a marker of severe peripheral diabetic neuropathy and foot sepsis.

BACKGROUND: Peripheral neuropathy is a major contributor to diabetic foot complications including ulceration, sepsis and limb loss. The aim of this study was to document the frequency of this previously undocumented clinical marker of peripheral neuropathy, the "slipping slipper sign" (SSS), characterised by unrecognised loss of slippers from one's feet while walking, and to compare it with traditional clinical tests for peripheral neuropathy. OBJECTIVE: To evaluate the relationship between a positive SSS and diabetic peripheral neuropathy. SUBJECTS AND METHODS: The study included 105 diabetic outpatients without active foot problems, 40 diabetic inpatients with active foot sepsis, and 69 other patients with neither diabetes nor active foot sepsis as negative controls. Demographic data, clinical neuropathy scores and the presence or absence of the SSS were obtained. RESULTS: No control subjects had a positive SSS. In contrast, 64 of 145 diabetic patients had severe neuropathy of whom 53 had a positive SSS (83% sensitivity) and 74 of 81 without severe neuropathy had a negative SSS (91% specificity). Diabetic patients with concurrent foot sepsis had a higher frequency of severe neuropathy (70%) and positive SSS (65%) compared with those without (36% and 35%, respectively, p<0.001). Multivariate analysis showed that a positive SSS was strongly related to severity of neuropathy independent of duration of diabetes. CONCLUSION: The SSS reflects severe peripheral neuropathy and is particularly prevalent among those with active foot disease. Patients who have experienced the SSS should be encouraged to seek attention and preventive action taken.

Traumatic diaphragmatic herniation presenting as a delayed tension faecopneumothorax.

This article reports an unusual case of delayed presentation of a tension faecopneumothorax after traumatic injury to the diaphragm 5 years previously. Three important clinical lessons are highlighted: (a) for suspected tension pneumothorax, if a considerable quantity of serous fluid is drained in addition to air, a communication with the peritoneal cavity should be considered; (b) spontaneous tension pneumothorax is an extremely rare condition and other causes should be kept in mind; and (c) in the presence of a tension pneumothorax and diaphragmatic hernia, the contents of the visceral sac may be completely reduced and the hernia may be masked.

Delayed repair of a fractured penis: a new technique.

Fracture of the penis can be managed conservatively or surgically. Conservative management is associated with a high morbidity, and early surgical repair of the fracture is usually recommended in order to prevent complications. Because a fractured penis is swollen throughout its length, it is difficult to identify the fracture site accurately, so a degloving technique is usually used to locate and repair the torn corpus cavernosum; this can lead to further trauma and complications. In cases where extensive swelling makes accurate clinical localisation difficult, delaying the repair for 7-12 days facilitates easy identification and repair of the torn corpus cavernosum. We report three cases where treatment was delayed until the swelling had subsided, when a simple direct repair was successfully carried out.

McBurney's point: are we missing it?

A prospective study of 100 post-evacuation barium enemas was done. Films were centered at McBurney's point, with an opaque skin marker at that point. Analysis of these revealed that in only one case (1%) was the base of the appendix at McBurney's point. In 67% it was cephalic and in 32% it was caudal to this point. The limitations of McBurney's point as an anatomical landmark should be recognized. This needs to be highlighted in teaching anatomy, especially to surgical trainees. Planning and choice of surgical incisions should be based on an understanding of these anatomical variations since McBurney's original description was clinical rather than anatomical.

Late small bowel obstruction after blunt abdominal trauma.

Blunt abdominal trauma with intraperitoneal injury usually presents acutely. On rare occasions, such patients can present later on with features of small bowel obstruction due to stricture formation. It is thought that such a delayed stricture is due to subclinical bowel perforation, localised gut ischaemia, or injury to the mesenteric vasculature. This case demonstrates the mesenteric vascular injury theory to be the cause of the bowel stricture.

Slow decompression of the bladder using an intravenous giving set.

Rapid decompression of the bladder has been associated with complications such as diuresis, hyperkalaemia, haematuria and hypotension. Although these complications are easily managed and rarely clinically significant, clinicians still practise slow decompression using a 'clamping' technique. Slow decompression using a giving set provides a more convenient and less time-consuming way of achieving this goal.

Pedicled flaps in reconstructive surgery.

An audit was conducted of pedicled flaps used in reconstructive surgery in Trinidad from 1983 to 2000. This consisted of 65 flaps. There were four cases of partial flap necrosis: three involving tram flaps and the other involving the metacarpal artery flap. There were no cases of total flap loss. Pedicled flap coverage provides immediate closure of potentially difficult wounds. This early cover reduces the risk of infection as a result of increasing the blood supply and providing a physical barrier. This contributes to a shorter hospital stay and earlier rehabilitation. Our present team approach with the inclusion of a reconstructive surgeon now allows for uncompromised débridement in trauma and oncological resection.

Closure of traumatic wounds without cleaning and suturing.

BACKGROUND: In less than ideal situations wounds have to be closed without extensive cleaning using sterile adhesive strips (Steristrips). This prospective analyses the efficiency of this technique and compares it to the more conventional approach. METHODS: Altogether 147 lacerations were closed with sterile strips with no wound cleaning. Patients were subsequently followed up for a minimum of three months. RESULTS: The sepsis rate in compliant patients was 1.4% with a total complication rate of 2.7%. CONCLUSION: This technique, while contradicting the "sacred tenets" of wound closure, is a cheap, quick, and effective alternative to routine closure of traumatic wounds in a casualty department.

Obturator hernia repair--a new technique.

Obturator hernia is a rare condition with few reports in the world literature. There appears to be no consensus on the ideal approach and repair for such a condition. We report a simple, quick technique via a lower midline incision using an autogenous peritoneal fold. It is ideal for the contaminated case and in settings where mesh is not readily available.

Pedicled flaps in reconstructive surgery

An audit was conducted of pedicled flaps used in reconstructive surgery in Trinidad from 1983 to 2000. This consisted of 65 flaps. There were four cases of partial flap necrosis: three involving tram flaps and the other involving the metacarpal artery flap. There were no cases of total flap loss. Pedicled flap coverage provides immediate closure of potentially difficult wounds. This early cover reduces the risk of infection as a result of increasing the blood supply and providing a physical barrier. This contributes to a shorter hospital stay and earlier rehabilitation. Our present team approach with the inclusion of a reconstructive surgeon now allows for uncompromised dÚbridement in trauma and oncological resection.

Management of hyperthyroidism in Trinidad and Tobago.

A questionnaire study of current practices regarding the investigation and treatment of hyperthyroidism was undertaken in Trinidad and Tobago between December 1999 and March 2000. The study evaluated the choice of laboratory tests requested and the therapeutic choices for a standard patient with hyperthyroidism. In addition, clinical scenarios based upon variations of the standard case (by altering age, gender, goitre size and duration of disease) were also tested. Two hundred and ninety-six questionnaires were sent; 134 (45%) were returned, of which four were excluded for incomplete data. Ninety five per cent of respondents requested biochemical confirmation but the range of tests varied widely. Thyroid scintigraphy was requested by 36% and thyroid ultrasound by 35%. Medical treatment (75%) with antithyroid drugs was the most popular choice for treatment of the standard patient. This did not change significantly if the patient was male. On the other hand, radioiodine (62%) was more popular in the treatment of chronic/relapsing hyperthyroidism (p < 0.005). In the elderly, medical management was still the most popular choice (57%) but the choice of radioiodine therapy was significantly increased compared with that in the standard patient (36% vs 19%) (p<0.005). In a young female with a large goitre and chronic disease, surgical intervention (61%) was the treatment of choice, especially among surgeons and general practitioners; radioiodine was chosen by 28% of respondents (mostly internists). There is need for clear guidelines in investigating thyroid disease but therapeutic choices are well informed and consistent with accepted practice elsewhere. In particular there is a fairly liberal attitude towards radioiodine use in hyperthyroidism.

Rectus sheath haematoma: a new set of diagnostic features.

Rectus muscle haematoma is a well documented clinical entity, but its diagnosis remains elusive. A haematoma within the rectus sheath produces a painful, tender swelling that can mimic an intraperitoneal mass with features of an acute abdomen. Two patients with rectus haematomas presenting after bouts of prolonged coughing are reported. In both cases, clinical features and ultrasound findings suggested the presence of intraperitoneal pathology. However, in both cases consistent findings in the history and examination pointed towards the diagnosis of a rectus haematoma. It is proposed that these simple clinical criteria are diagnostic of a rectus sheath haematoma, and can thereby avert an unnecessary laparotomy.