Dale Maharaj

Obturator hernia repair – a new technique

Abstract. 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.

Open mini-access ureterolithotomy: the treatment of choice for the refractory ureteric stone?

To report the experience in one centre of the efficacy and safety of open mini‐access ureterolithotomy (MAU) and to discuss relevant current indications.

Management of Giant Fibroadenomas: A Case for Small Incisions for Large Tumors

To the Editor: The optimal management for treatment of large or giant fibroadenomas remains controversial. Patients with giant fibroadenomas should be treated with the assumption that the lesion is benign, and therefore local excision is the treatment of choice (1). The inframammary incision is in fact an excellent option for excising these large tumors with conservation of the breast, and certainly is preferred to mastectomy (2). However, the submammary scar is not hidden by the nonpendulous breast of both developing females and those with smaller breasts. Even with pendulous breasts, when lying supine such that the effect of gravity is negated, the patient may be embarrassed by the presence of a large inframammary scar. This becomes even more apparent in our setting where, with a high proportion of patients of African origin, keloids and hypertrophic scarring are common. We have described removal of these large tumors using a circumareolar incision (3). By cutting the lesion in the shape of a Swiss roll, the mass can be removed in its entirety. As the breast skin is stretched, quite a large circumareolar incision can be made. This shrinks back to normal after removal of the fibroadenoma. Use of the circumareolar incision causes little disruption of the breast tissue (4). Our Swiss-roll operation allows these large tumors to be removed through a cosmetically acceptable, small circumareolar incision.

Surgical management of exertional anterior compartment syndrome of the leg

OBJECTIVE To describe the characteristic presentation of exertional leg pain in athletes and to discuss the diagnostic options and surgical management of exertional anterior compartment syndrome of the leg in this group of patients. METHODS Data from a series of athletes presenting with exertional leg pain were analysed and categorized according to aetiology. RESULTS Sixty-six athletes presenting with exertional leg pain in 102 limbs were analysed. Sixteen patients in a first group of 20 patients with a provisional diagnosis of exertional anterior compartment syndrome of the leg underwent a closed fasciotomy with complete resolution of symptoms. A second group of 42 patients were diagnosed as medial tibial stress syndrome and a third group of four patients had confirmed stress fracture of the tibia. CONCLUSION Exertional leg pain is a common presenting complaint of athletes to sports physicians and physiotherapists. Careful analysis can lead to an accurate diagnosis and commencement of effective treatment. Exertional anterior compartment syndrome can be successfully treated utilizing a closed fasciotomy with a rapid return to sport.

Charcot‐marie‐tooth disease presenting as a nonhealing ulcer in a 26‐year‐old man

A 26‐year‐old man presented with a nonhealing ulcer on the plantar aspect of the left foot of five years duration. Initial investigations were unremarkable. It was only after careful neurological examination that an inherited neuropathy was suspected. This was confirmed by nerve conduction studies and serum electrophoresis. He subsequently underwent partial great toe amputation for the ulcer and underlying first phalangeal osteomyelitis with uneventful healing. Neuropathic ulcers are usually associated with several well‐known disorders including diabetes mellitus, tabes dorsalis, pernicious anemia, and sickle cell disease. A rarer cause is Charcot‐Marie‐Tooth Disease (CMTD). The report gives a review of CMTD and emphasizes that when faced with a nonhealing ulcer in the younger age group, such an underlying hereditary neuropathic cause must be considered.

Relationship of Ethnicity and Histologic Type of Breast Carcinoma in a West Indian Population

To the Editor: Breast cancer and ethnicity have been studied mainly in first-world countries including the United States (1,2) and the United Kingdom (3) as it relates to incidence, prevalence, and survival in mainly white and black races. However, there is a paucity of data from the third world including the West Indies. Trinidad & Tobago is an island located in the southernmost part of the Caribbean Sea adjacent to the South American coast. It has a very diverse racial mixture of persons of African (43%) and East Indian descent (41%), which accounts for most of the population. These persons are fourth-generation descendants of East Indian and African laborers who were brought here in the late 1800s from the African and Indian continents to work on plantations. Fifteen percent of the populace consists of persons of mixed descent and Caucasians, while Chinese and Arabs account for less than 1%. It is thus an excellent location for studying the relationship of ethnicity and breast cancer. A 2-year retrospective analysis of breast carcinomas at the General Hospital, Port-of-Spain, Trinidad, West Indies, was conducted. Data were collected from the operating theater books and pathology records focusing on age, ethnicity, and histologic type of breast carcinoma in order to establish the relationship between these parameters. The results showed Afro-Caribbean women were the most commonly affected group (54% of cases), with Indo-Caribbean women accounting for 35% of cases. Mixed races accounted for 11%. The most common age group affected were those patients 53 to 59 years of age. Invasive ductal carcinoma (IDC) was the most commonly occurring histologic type (70% of 299 cases in 2 years), with invasive lobular carcinoma (ILC) accounting for 17%. Afro-Caribbean women were twice as likely to develop IDC and ILC compared to Indo-Caribbean women. Medullary, papillary, and mucinous adenocarcinoma types occurred 4%, 2%, and 3% of the time, respectively, and there were some other rare histologic types accounting for less than 4% of cases. These included squamous, tubular, and comedo carcinomas, sarcoma, mesenchymal chondrosarcoma, and a very rare case of carcinoma occurring in a phyllodes tumor. Most of the data from the United States focuses on comparing the similarities and differences in histology, biology, and survival of blacks and whites with breast cancer (1,2) and in the United Kingdom the focus has been mainly on incidence (3). It is well documented that survival after breast cancer diagnosis is significantly worse among African American women and that the age of diagnosis is significantly younger (4,5). In summary, the data presented is far from complete; however, it still provides information previously unavailable in such a diverse racial mixture in the third-world island population of Trinidad & Tobago. Two points are highlighted from this data: There is clearly a greater chance of AfroCaribbean women developing breast cancer than other races; and there is an unusually high incidence of ILC (17%) in the Trinidad population compared with global data (<4%). We propose a more detailed and thorough analysis in relation to this topic, focusing more on genetic studies to determine the cause of this trend.

A male patient from the West Indies with invasive ductal carcinoma in the right breast: A case report and literature review

BACKGROUND Men with breast carcinoma have a poor prognosis, especially in the younger age group (30-40 years of age), because most breast enlargements in young men are dismissed as gynecomastia, resulting in an unnecessary delay in treatment. OBJECTIVE We describe the case of a young male patient with invasive ductal breast carcinoma. CASE SUMMARY In November 2005, a 30-year-old Afro-Caribbean man presented at St. Clair Medical Centre in Port of Spain, Trinidad, with a painless lump in the right breast. Diagnostic findings revealed that the patient had stage II invasive ductal carcinoma, for which he underwent a mastectomy with total axillary clearance. CONCLUSION Surgeons investigating unilateral breast swellings in young males should not dismiss them simply as gynecomastia, and should be wary of cancer.

A twist in diagnosis.

A 52-year-old male weighing 74 kg presented with a twoday history of colicky pain in the supra-umbilical region. He complained of nausea and anorexia. On the day of presentation, his pain migrated to the right iliac fossa and became constant. Examination revealed a pulse of 90 bpm with a temperature of 98.7 F. He was found to be tender in the right iliac fossa with voluntary guarding and rebound. His white cell count was found to be 11.3 per m with a shift in the neutrophils to the left. His MANTREL score was estimated at 9. A mini-Lanz incision approach for appendicectomy was performed. Serosanguineous peritoneal fluid was noted on entering the cavity. The appendix was macroscopically noninflamed. Intraperitoneal ischemia was suspected at this time, and on mobilization of the intraperitoneal contents, a 1080 torsion of a 8 10 cm lip of omentum was noted (Fig. 1). The ischemic segment was excised between ligatures. An incidental appendicectomy was performed. The patient recovered uneventfully.

Distal-to-Snuffbox Arteriovenous Fistula

&NA; The dogma for optimal arteriovenous fistula (AVF) creation is based on starting as distally as possible on the upper limb and progressing proximally. We herein present our findings of an AVF that is as distal as possible on the hand. To document primary patency rates of the distal‐to‐snuffbox AVF. A 10‐year prospective study (2006‐2016) involving 31 patients whose distal cephalic vein diameter was ≥3 mm with a normal Allens test was conducted. Patients were excluded if the radial artery in the wrist was highly calcified, the cephalic vein did not dilate more than 3 mm with proximal compression, and there was previously failed AVF of the limb or previous trauma to the limb. The procedure was performed under local anesthetic, and the anastomosis performed with a 6.0 polypropylene suture in an end‐to‐side fashion. Thirty‐one patients with end‐stage renal disease underwent distal vascular access using the distal‐to‐snuffbox (Hitchhikers) AVF (HAVF). During follow‐up, eight patients died with an adequately functioning HAVF. The primary patency rates at 12, 24, 48, and 60 months were 90, 87, 85, and 82%, respectively. Failure occurred in six (19%) cases over the follow‐up period, two in the first 2 weeks and four over a span of 60 months. Conclusion The creation of radiocephalic AVFs in the first web space, distal to the tendon of the extensor pollicis longus, serves as a viable option with acceptable success rates. This allows the surgeon more options with proper patient selection for this procedure.

Rectus Sheath Hematoma: A Series of Unfortunate Events

We read with great interest the article entitled ‘‘Rectus Sheath Hematoma: A Series of Unfortunate Events’’ by Luhmann and Williams [1]. The condition, as they quite rightfully stated, is rare and difficult to diagnose. They mentioned Fotherhill’s sign as being a useful test for distinguishing intraperitoneal masses from masses arising from the abdominal wall. This is an interesting relation to Carnett’s test [2] in which tenderness arising from intraperitoneal pathology is reduced on contraction of the abdominal musculature. Carnett’s article was also published in 1926. We have found that rectus sheath hematomas have the following consistent features [3].