Surgical training in the Caribbean: The past, the present, and the future.

The six million inhabitants of these diverse English-speaking Caribbean countries are grateful to the University of the West Indies, which has been central in the independent training of surgical specialists in all areas of surgery for the past 50 years. Similar to the per capita income, the quality of surgical care, albeit acceptable, is quite variable throughout the region. Globalization and access to information have revealed that the quality of training and surgical care being delivered can be further improved. Technological advances will perhaps never be on par with higher-income countries, but collaborative ventures with global health partners and institutions can ensure that the people of the region will have appropriately trained surgical doctors and, therefore, the provision of accessible quality care will remain a staple, with even the possibility of income generation. This study reviews the journey of our structured surgical training program delivered in the region and outlines our growth plans.

Arteriovenous fistulas as vascular access for hemodialysis: The preliminary experience at the University Hospital of the West Indies, Jamaica.

BACKGROUND: The demand for vascular hemodialysis access creation is steadily increasing. To satisfy the demand, a vascular access team was established at the University Hospital of the West Indies, Jamaica. The outcomes of this practice are reported. METHODS: A retrospective study of all patients who had permanent vascular dialysis access established at the University Hospital of the West Indies between January 1, 2002, and December 31, 2006, was performed. Data were analyzed using SPSS version 12.0 (SPSS Inc, USA). A direct anastomosis between an autogenous artery and vein was considered an arteriovenous fistula (AVF). When prosthetic material was used, the access was considered to be an arteriovenous graft. Accesses that were nonfunctional after six weeks of maturation were considered to be primary failures, while those that failed after previous successful dialysis were considered to be secondary failures. Primary patency was defined as the interval between access placement and the first intervention for failure. Secondary patency was the interval between access placement and abandonment. Cumulative patency was defined as the number of accesses that remained patent over a given time period, regardless of the number of interventions performed. RESULTS: Of 41 patients, nine were excluded due to incomplete data. Final analyses were performed on 32 patients with a mean (± SD) age of 42.3±15.3 years (range 18 to 66 years, median 43 years). The access type was an AVF in 100% of cases, which included distal radiocephalic fistulas in 27 patients, brachial-cephalic fistulas in three patients and proximal radiocephalic fistulas in two patients. Operations were performed in four (12.5%) incident and 28 (87.5%) prevalent dialysis patients. The mean delay between initiation of dialysis and AVF creation was 21.2±26.1 months (range one to 94 months, median 10 months). There were eight (25%) primary failures. Of the remaining 24 patients, there were seven (29.2%) secondary failures from thrombosis. There was primary patency for a mean of 723.9±422.1 days (range 199 to 1314 days, median 678 days). Only one (4.2%) patient had thrombectomy to prolong AVF function, resulting in secondary patency for 439 days. Cumulative patency was 62.5%, 33.3%, 25% and 4.2% for one, two, three and four years, respectively. CONCLUSIONS: The rate of AVF creation for end-stage renal disease patients in this setting far exceeds the target goals set forward by the National Kidney Foundation published updated Dialysis Outcomes Quality Initiative (NKF/DOQI) Guidelines and the Centers for Medicaid & Medicare Services Fistula First initiative. This is being achieved with acceptable rates of morbidity and patency. There is room for improvement in postoperative surveillance to increase early detection of failing accesses and allow for increased utility of interventions for assisted patency.

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. (AU)

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

Granulomatous labour 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 exclusion has been the traditional therapeutic modality, the most appropriate therapy seems to involve the use of corticosteriods, even in the case of recurrence. (AU)

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 symptomic 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 non-operative treatment of symptomatic solitary hepatic cysts. (AU)