Role of oral antibiotics for prophylaxis against surgical site infections after elective colorectal surgery

Over the past few decades, surgeons have made many attempts to reduce the incidence of surgical site infections(SSI) after elective colorectal surgery. Routine faecal diversion is no longer practiced in elective colonic surgery and mechanical bowel preparation is on the verge of being eliminated altogether. Intravenous antibiotics have become the standard of care as prophylaxis against SSI for elective colorectal operations. However, the role of oral antibiotics is still being debated. We review the available data evaluating the role of oral antibiotics as prophylaxis for SSI in colorectal surgery.

Overexpression of Slug is associated with malignant progression of esophageal adenocarcinoma

AIM: To characterise expression of known E-cadherin repressors; Snail, Slug and Twist in the development of esophageal adenocarcinoma. METHODS: E-cadherin, Slug, Snail and Twist mRNA expression in Barrett's metaplasia and esophageal adenocarcinoma specimens was examined by real-time reverse transcription-polymerase chain reaction (RT-PCR). Semi-quantitative immunohistochemistry was used to examine cellular localisation and protein levels. The effect of Slug on epithelial mesenchymal transition (EMT) markers was examined by transfection of Slug into an adenocarcinoma line OE33.RESULTS: Cellular localisation of Slug in Barrett's metaplasia was largely cytoplasmic whilst in adenocarcinoma it was nuclear. Semi-quantitative analysis indicated that Slug was more abundant in adenocarcinoma compared to matched Barrett's metaplastic specimens. Snail and Twist were expressed in adenocarcinoma but were cytoplasmic in location and not induced compared to Barrett's mucosa. These observations were supported by mRNA studies where only Slug mRNA was shown to be over-expressed in adenocarcinoma and inversely correlated to E-cadherin expression. Overexpression of Slug in OE33 mediated E-cadherin repression and induced the mesenchymal markers vimentin and fibronectin.CONCLUSION: Progression to adenocarcinoma is associated with increased Slug expression and this may represent a mechanism of E-cadherin silencing.

Review of minimally invasive pancreas surgery and opinion on its incorporation into low volume and resource poor centres

Pancreatic surgery has been one of the last areas for the application of minimally invasive surgery(MIS)because there are many factors that make laparoscopic pancreas resections difficult.The concept of service centralization has also limited expertise to a small cadre of high-volume centres in resource rich countries.However,this is not the environment that many surgeons in developing countries work in.These patients often do not have the opportunity to travel to high volume centres for care.Therefore,we sought to review the existing data on MIS for the pancreas and to discuss.In this paper,we review the evolution of MIS on the pancreas and discuss the incorporation of this service into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating all studies published on laparoscopic and robotic surgery of the pancreas.The data in the Caribbean is examined and we discuss tips for incorporating this operation into resource poor hospital practice.Low pancreatic case volume in the Caribbean,and financial barriers to MIS in general,laparoscopic distal pancreatectomy,enucleation and cystogastrostomy are feasible operations to integrate in to a resource-limited healthcare environment.This is because they can be performed with minimal to no consumables and require an intermediate MIS skillset to complement an open pancreatic surgeon’s peri-operative experience.

Anatomic variations of the intra-hepatic biliary tree in the Caribbean:A systematic review

BACKGROUND In the classic descriptions of the human liver,the common hepatic duct forms at the confluence of left and right hepatic ducts.Many authors have documented variations in the intra-hepatic ductal system,but to the best of our knowledge there has been no report on bile duct variations in Caribbean populations.AIM To evaluate the variations in bile duct anatomy using magnetic resonance cholangiography(MRC)in unselected patients at a major hepatobiliary referral centre in the Eastern Caribbean.Knowledge of the intra-hepatic biliary anatomy is important to optimize service delivery for any physician treating liver and biliary disorders.METHODS This study was carried out at a tertiary referral hospital for hepatobiliary diseases in the Eastern Caribbean.We retrospectively evaluated magnetic resonance cholangiograms in 152 consecutive patients at this facility over a two-year period from April 1,2017 to March 31,2019.Two consultant radiologists experienced in MRC interpretation reviewed all scans and described biliary anatomy according to the Huang’s classification.A systematic review of published studies was performed and relevant data were extracted in order to calculate the global prevalence of each biliary variant.The variants in our population were compared to the global population.RESULTS There were 152 MRCs evaluated in this study in 86 males and 66 females.There were 109(71.7%)persons with“classic”biliary anatomy(type A1)and variants were present in 43(28.3%)persons.There was no statistical relationship between the presence of anatomic variants and gender or ethnicity.We encountered the following variants:29(19.1%)type A2,7(4.6%)type A3,6(3.95%)type A4,0 type A5 and a single variant(quadrification)that did not fit the classification system.Compared to the global prevalence,our population had a significantly greater occurrence of A1 anatomy(71.7%vs 62.6%;P=0.0227)and A2 trifurcations(19.1%vs 11.5%;P=0.0069),but a significantly lower incidence of A3 variants(4.61%vs 11.5%;P=0.0047).CONCLUSION There are significant differences in intra-hepatic biliary anatomy in this unselected Eastern Caribbean population compared to global statistics.Specifically,persons of Caribbean descent have a greater incidence of Huang A2 trifurcations and a lower incidence of Huang A3 variants.

Clinical outcomes after major hepatectomy are acceptable in low-volume centers in the Caribbean

BACKGROUND Major hepatectomies are routinely performed because they are often the only curative treatment for metastatic liver disease.There has been a trend to concentrate major hepatectomies in referral hospitals that perform these operations at high volumes.These high volume referral centers are usually located in developed countries,but many patients in developing nations are not able to access these centers because of financial limitations,lack of social support and/or travel restrictions.Therefore,local hospitals are often the only options many of these patients have for surgical treatment of metastatic liver disease.This is the situation in many Caribbean countries.AIM To determine the clinical outcomes after major liver resections in a low-resource hepatobiliary center in the Caribbean.METHODS We prospectively studied all patients who underwent major liver resections over five years.The following data were extracted:patient demographics,diagnoses,ECOG status,operation performed,post-operative morbidity and mortality.Statistical analyses were performed using SPSS ver 16.0 RESULTSThere were 69 major liver resections performed by two teams at a mean case volume of 13.8 major resections/year.Sixty-nine major hepatic resections were performed for:colorectal liver metastases 40(58%),non-colorectal metastases 9(13%),hepatocellular carcinoma 8(11.6%),ruptured adenomas 4(5.8%),hilar cholangiocarcinomas 4(5.8%),hemangiomata 2(2.9%),trauma 1(1.5%) and hepatoblastoma 1(1.5%).Twenty-one patients had at least one complication,for an overall morbidity rate of 30.4%.There were minor complications in 17(24.6%)patients,major complications in 11(15.9%) patients and 4(5.8%) deaths.CONCLUSION There are unique geographic,political and financial limitations to healthcare delivery in the Caribbean.Nevertheless,clinical outcomes are acceptable in the established,low-volume hepatobiliary centers in the Eastern Caribbean.

Caribbean “substitution culture” is a barrier to effective treatment of persons with diabetic foot infections

Diabetes-related amputation rates are high in the Caribbean. Many authorities have identified independent risk factors for diabetes-related amputations, but cultural factors remain underappreciated. We coined the term “Caribbean substitution culture” to describe the attitude of patients with diabetic foot infections in which they refuse to access medical care, instead voluntarily choosing to substitute “bush medicines” or other alternative therapies in the place of conventional treatment. Recognizing that the Caribbean substitution culture is a barrier to effective treatment of diabetic foot infections is the first step in curbing these practices. In this paper, we discuss the issues related to the Caribbean substitution culture, including the demographics of the population at risk, the alternative therapeutic practices and potential public health strategies to combat this practice.

Liver resection for cancer

HISTORY OF HEPATIC RESECTIONThe earliest hepatic surgery was almost exclusively performed for trauma with records from as for tumor were those of Langenbuch in 1888 [3] , Tiffany in 1890 [4],and Lucke in 1891[5].By1899,76 cases of liver resection had been reported with a mortality rate of 14.9% [6], a remarkably low figure for operations of this magnitude,all performed at the end of the 19th century.

Whipple’s operation with a modified centralization concept:A model in low-volume Caribbean centers

Conventional data suggest that complex operations,such as a pancreaticoduodenectomy(PD),should be limited to high volume centers.However,this is not practical in small,resource-poor countries in the Caribbean.In these settings,patients have no option but to have their PDs performed locally at low volumes,occasionally by general surgeons.In this paper,we review the evolution of the concept of the high-volume center and discuss the feasibility of applying this concept to low and middle-income nations.Specifically,we discuss a modification of this concept that may be considered when incorporating PD into low-volume and resource-poor countries,such as those in the Caribbean.This paper has two parts.First,we performed a literature review evaluating studies published on outcomes after PD in high volume centers.The data in the Caribbean is then examined and we discuss the incorporation of this operation into resource-poor hospitals with modifications of the centralization concept.In the authors’opinions,most patients who require PD in the Caribbean do not have realistic opportunities to have surgery in high-volume centers in developed countries.In these settings,their only options are to have their operations in the resource-poor,low-volume settings in the Caribbean.However,post-operative outcomes may be improved,despite low-volumes,if a modified centralization concept is encouraged.

急症处理:闭角型青光眼

急性闭角型青光眼是一种眼科急症,如果没有立即诊断和治疗它可能导致不可逆转的失明。表现患者可能会有红眼疼痛,头痛,视力模糊,头晕,恶心,呕吐和腹痛(有时被误诊为胃肠炎)。诱发因素包括夜光和某些药物(如支气管扩张剂,咳嗽合剂,感冒和流感药物,抗抑郁药,抗组胺药和抗惊厥药)。

COVID-19 and its effects upon orthopaedic surgery: The Trinidad and Tobago experience

The World Health Organisation(WHO)declared coronavirus disease 2019(COVID-19)a pandemic on March 11,2020.COVID-19 is not the first infectious disease to affect Trinidad and Tobago.The country has faced outbreaks of both Chikungunya and Zika virus in 2014 and 2016 respectively.The viral pandemic is predicted to have a significant impact upon all countries,but the healthcare services in a developing country are especially vulnerable.The Government of Trinidad and Tobago swiftly established a parallel healthcare system to isolate and treat suspected and confirmed cases of COVID-19.Strick‘lockdown’orders,office closures,social distancing and face mask usage recommendation were implemented following advice from the WHO.This approach has seen Trinidad and Tobago emerge from the second wave of infections,with the most recent Oxford COVID-19 Government Response Tracker report indicating a favourable risk of openness index for the country.The effects of the pandemic on the orthopaedic services in the public and private healthcare systems show significant differences.Constrained by shortages in personal protective equipment and inadequate testing facilities,the public system moved into emergency mode prioritizing the care of urgent and critical cases.Private healthcare driven more by economic considerations,quickly instituted widespread safety measures to ensure that the clinics remained open and elective surgery was not interrupted.Orthopaedic teaching at The University of the West Indies was quickly migrated to an online platform to facilitate both medical students and residents.The Caribbean Association of Orthopedic Surgeons through its frequent virtual meetings provided a forum for continuing education and social interaction amongst colleagues.The pandemic has disrupted our daily routines leading to unparalleled changes to our lives and livelihoods.Many of these changes will remain long after the pandemic is over,permanently transforming the practice of orthopaedics.

Responses to disrupted operative care during the coronavirus pandemic at a Caribbean hospital

The coronavirus pandemic was thrust upon all nations in the year 2020 and required swift public health responses.Resource-poor health care facilities,such as those in the Caribbean,were poorly prepared but had to respond to the threat.In this experience report we examined the response by the surgical specialty to evaluate the lessons learned and to identify positive changes that may continue post-pandemic.

Therapy for <i>H.</i><i>pylori</i>: Current concepts

Helicobacter pylori plays an important role in the pathogenesis of chronic active gastritis, peptic ulcer and gastric mucosa-associated lymphoid tissue-lymphoma, and is also involved in carcinogenesis of the stomach. Since now no current first-line therapy is able to cure the infection in all treated patients. We evaluated data on the most successful therapy regimens—sequential, concomitant and quadruple therapies—and on the standard therapy available for H. pylori eradication. When therapy fails several factors may be involved: we reviewed both bacterial and host factors that can affect the eradication and that can be involved in therapeutic management of the H. pylori infection.

Adrenal insufficiency and bowel obstruction: An overlooked association

Bowel obstruction is a documented but rare presentation of adrenal insufficiency (AI). We report a case of acute AI manifesting as intestinal pseudo-obstruction (IPO) in a patient with underlying iatrogenic adrenal suppression. An 83 years old female was admitted for partial small bowel obstruction that failed to resolve with conservative management. She then underwent exploratory laparotomy where no mechanical obstruction was found and the small bowel was manually decompressed. Postoperatively she developed acute swelling of her right ankle which was similar to mono-articular attacks in the past. This was diagnosed clinically as gout. Her obstruction failed to settle and a second laparotomy was done which yielded the same as the first. Given her past account of arthritic pain, direct questioning of steroid use unearthed a history of multiple intra-articular corticosteroid injections for analgesia. She also described several short courses of high dose oral steroids for respiratory tract infections, including a recent course which was abruptly stopped two days prior to presentation. Clinical suspicion of AI was supported by biochemical testing of stress cortisol levels and change in the serum cortisol in response to 250 μg of synthetic adrenocorticotropic hormone. Moreover, her improvement following a therapeutic trial of steroid replacement was dramatic and strongly supports this diagnosis. It is therefore worthwhile to consider a diagnosis of AI in cases of bowel obstruction in patients with comorbidities that predispose to steroid use and especially in settings where steroid abuse is prevalent.

Freehand-robot-assisted laparoscopic colorectal surgery:Initial experience in the Trinidad and Tobago

BACKGROUND Laparoscopic colorectal surgery is still developing in the Anglophone Caribbean,having been first performed in the region in the year 2011.We report the initial outcomes using a robot camera holder to assist in laparoscopic colorectal operations.AIM To report our initial experience using the FreeHand®robotic camera holder(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)for laparoscopic colorectal surgery in Trinidad&Tobago.METHODS We retrospectively collected data from all patients who underwent laparoscopic colorectal resections using the Freehand®(Freehand 2010 Ltd.,Guildford,Surrey,United Kingdom)robotic camera holder between September 30,2021 and April 30,2022.The following data were recorded:patient demographics,robotic arm setup time,operating time,conversions to open surgery,conversions to a human camera operator,number and duration of intra-operative lens cleaning.At the termination of the operation,before operating notes were completed,the surgeons were administered a questionnaire recording information on ergonomics,user difficulty,requirement to convert to a human camera operator and their ability to carry out effective movements to control the robot while operating.RESULTS Nine patients at a mean age of 58.9±7.1 years underwent colorectal operations using the FreeHand robot:Right hemicolectomies(5),left hemicolectomy(1),sigmoid colectomies(2)and anterior resection(1).The mean robot docking time was 6.33 minutes(Median 6;Range 4-10;SD±1.8).The mean duration of operation was 122.33±78.5 min and estimated blood loss was 113.33±151.08 mL.There were no conversions to a human camera holder.The laparoscope was detached from the robot for lens cleaning/defogging an average of 2.6±0.88 times per case,with cumulative mean interruption time of 4.2±2.15 minutes per case.The mean duration of hospitalization was 3.2±1.30 days and there were no complications recorded.When the surgeons were interviewed after operation,the surgeons reported that there were good ergonomics(100%),with no limitation on instrument movement(100%),stable image(100%)and better control of surgical field(100%).CONCLUSION Robot-assisted laparoscopic colorectal surgery is feasible and safe in the resource-poor Caribbean setting,once there is appropriate training.

轻量型网片可以提高腹腔镜全腹膜外腹股沟疝修补术后的功能结局

前瞻性研究旨在比较腹腔镜全腹膜外腹股沟疝修补术(TEP)中,采用新型轻量型网片和传统重量型网片的差异,所有手术均在同一疝中心完成。方法自2004年11月到2005年7月,共有250例病人接受了腹腔镜TEP,采用轻量型(Ultrapro,30g/m)2或重量型网片(Prolene,100g/m2)。通过病历资料回顾及电话问卷调查获得随访数据。术后早期及远期均对病人进行随访,以评估术后结局的变化。结果 250例中有188例(75%)获得随访。在术后平均4个月及15个月进行的随访中发现,轻量型网片组和重量型网片组在疼痛或不适感的发生率及程度上没有差别。轻量型网片组在术后早期及远期对体力活动的影响显著小于重量型网片组,尤其是举重(9%vs.21%,平均随访4个月,Mann-WhitneyU,P=0.024)、行走(1%vs.11%,平均随访5个月,Mann-WhitneyU,P=0.006)及剧烈运动(7%vs.19%,平均随访15个月,Mann-Whitney-U,P=0.012)。腹股沟区的网片感或不适感两组差异无统计学意义。结论采用轻量型网片行腹腔镜TEP可以改善术后早期及远期的功能结局。轻量型网片可以显著减少对所有体力活动的影响。两者的疼痛都较轻微,表明腹腔镜手术的优势。