Dilip Dan

Trends in breast cancer mortality in Trinidad and Tobago—A 35-year study

BACKGROUND Breast cancer is the most frequently diagnosed cancer among women worldwide. This study examines the breast cancer mortality patterns and trends in the Caribbean island state, Trinidad and Tobago for the 35-year period, 1970-2004. METHODS A retrospective analysis of the trends in breast cancer mortality from 1970 to 2004 was conducted. Crude mortality per 100,000 women, age-standardized mortality using World Standard population and age-stratified mortality were calculated and comparison was made between age groups above and below 50 years. RESULTS A general pattern of increase was observed in both crude and age-standardized mortality. The overall average crude mortality was 15.6 per 100,000 women (95% confidence interval (CI) 13.9-17.1) and the average age-standardized mortality was 18.0 per 100,000 women (95% CI 16.7-19.2). There was a pattern of increase in mortality with increasing age. The mortality rate was considerably higher for the age groups above 50 years than those less than 50 years of age both showing an upward trend over the 35-year period. CONCLUSIONS Breast cancer mortality continued to increase over the 35-year period in Trinidad and Tobago. This study did not identify the exact reasons for this increasing trend. However, it is known that Trinidad and Tobago is becoming much more industrialized. It may be speculated that decrease in fertility rates, increase in the incidence of obesity and hormone utilization could have influenced this trend.

Laparoscopic Management of a Massive Splenic Cyst

Splenic cysts are relatively uncommon entities in surgical practice and treatment options vary. We present a case of a young adult woman who presented with a left-sided abdominal mass. A large splenic cyst was diagnosed by abdominal ultrasound and computed tomography. Laparoscopic partial excision with marsupialisation was performed with uneventful recovery and minimal blood loss. Histopathology revealed an epidermoid cyst of the spleen. This report describes the case, and includes a short review of the literature. Laparoscopic partial excision with marsupialisation is a safe and appropriate method of treatment for large splenic cysts.

Perforated left-sided diverticulitis with faecal peritonitis: is the Hinchey classification the best guide for surgical decision making?

BackgroundAlthough the Hinchey scoring system has guided surgical decision making for perforated diverticulitis, what constitutes optimal surgical management is controversial. We report our experience of selective primary closure of the perforation without use of a transverse colostomy and the specific circumstances in which this may be safe.MethodsAll cases of perforated diverticular disease of the sigmoid colon with Hinchey grade IV (faecal) peritonitis seen over a 4-year period from one surgical unit were reviewed.ResultsPrimary closure without a diverting stoma was performed in six of the eight patients studied since the bowel was deemed healthy, and resection and primary end-to-end anastomosis were performed in the other two patients because there was associated scarring and stricture formation distally. In the primary closure patients, the site of the perforation was dissected and closed with attendant omentoplasty and a meticulous peritoneal toilet. In one of these cases, a diverting stoma was later fashioned after the patient developed a short-lived faecal fistula.ConclusionThe status of the underlying bowel, not the degree of peritoneal soiling, is the most significant consideration in defining the role of minimally invasive surgical treatment options for perforated diverticulitis. A new classification system that remains to be validated, taking into account the degree of colonic scarring and stricture formation, is proposed as a guide for surgical decision making in patients with perforated left-sided diverticulitis with faecal peritonitis.

Laparoscopic cholecystectomy in sickle cell disease patients: Does operating time matter?

OBJECTIVES To report the experience of performing laparoscopic cholecystectomy (LC) in patients suffering from sickle cell disease (SCD), and to assess if their postoperative complications can be minimized by shortening the operating time. METHODS Strict measures were taken to minimize the operating times and duration of pneumoperitoneum in SCD patients undergoing LC. Data collected included demographics, preoperative haemoglobin, the surgical technique used, operating times, insufflation pressures, perioperative complications and hospital length of stay. RESULTS In the 5-year period from July 2003 to June 2008, 19 patients with SCD underwent elective LC. Of these, 84% were female. The mean age was 21.5 years. The most common indication for surgery was symptomatic cholelithiasis (60%). The mean preoperative haemoglobin was 8.2g/dL. No preoperative blood transfusions were given. Four patients had preoperative endoscopic retrograde cholangiopancreatography (ERCP). Mean operating time was 27.9 min (range 20-45 min) which is 2.5-6 times quicker than most reports in the literature. There was no conversion to open surgery. Mean hospital length of stay was 2.5 days. Postoperative complications were noted in four patients with painful crises accounting for 50%. There was no mortality. CONCLUSION The study suggests that if stringent measures are taken to shorten the operating time, LC can be safely and effectively performed in SCD patients with minimal perioperative complications.

Umbilical Pilonidal Sinus: A New Treatment Technique of Sinus Excision with Umbilical Preservation

Under general anesthesia, careful inspection revealed a 3-mm ulcerated site in the depth of the umbilicus from which bits of hair protruded. A vertical skin incision through the umbilicus skirting one side of the sinuses was made. Diathermy cutting was used to minimize bleeding and ensure visibility of the lesion. There were several strands of hair projecting through three sinus openings (Figure 1). These communicated with a single subcutaneous tract that reached the sheath in the midline but did not branch laterally. All three openings and the tract were completely excised using a probe as a guide (Figure 2), approaching the tract superiorly, inferiorly, and laterally deep to the umbilicus, excluding the umbilical cicatrix and thus preserving it. The skin was closed primarily with subcuticular polypropylene, and the patient was given a course of antibiotics. He recovered uneventfully, had the sutures removed 10 days postoperatively, and has had no recurrence at 2 years.

Puncture Wounds in the Diabetic Foot: Importance of X-Ray in Diagnosis

It is well recognised that septic sequelae of puncture wounds are worse in diabetics. Since much of the spreading foot sepsis from puncture wounds is deep to the deep fascia, and because the sole of the foot has thick skin and subcutaneous fibrous septae, crepitus is not as easily appreciated as it is at other sites. Also the rubor of the inflammatory response is minimal in subfascial sepsis and it is therefore easy to underestimate the extent of deep gangrene. The absence of pain due to neuropathy also masks the inflammatory reaction and makes a foreign body or severe osteomyelitis less obvious clinically. These cases demonstrate the value of routine and early radiographs in the assessment of puncture wounds in diabetic feet.

Solid Pseudopapillary Neoplasms of the Pancreas: A Report of Two Cases

Solid pseudopapillary neoplasms of the pancreas are uncommon, accounting for only 1-2% of all pancreatic neoplasms. These tumors are being detected at an increased rate, probably due to the increased awareness and the liberal use of imaging. We report two cases of patients with solid pseudopapillary pancreatic tumors and review the existing literature.

Isolated endometriosis causing sigmoid colon obstruction: A case report

INTRODUCTION Isolated endometriosis of the intestine causing large bowel obstruction is rare. PRESENTATION OF CASE We present a case of endometriosis presenting as large bowel obstruction in a woman of childbearing age. She had no previous symptoms to suggest endometriosis and on presentation urgent surgery was required. The diagnosis of endometriosis was made only after pathological evaluation of the specimen. DISCUSSION No cases of endometriosis confined to this sigmoid colon without pelvic involvement were noted in the literature. CONCLUSION The diagnosis of endometriosis should be entertained when women of childbearing age presents with large bowel obstruction, whether or not the patient has other evidence of the disease.

A Case of Malignancy in a Thyroglossal Duct Cyst—Recommendations for Management

Thyroglossal duct cyst carcinomas are rare tumors with just more than 200 cases published to date. This is a case report of a thyroglossal duct cyst harboring an occult carcinoma for which a Sistrunk operation was performed. Histopathological examination revealed a papillary carcinoma arising from a thyroglossal duct cyst after which the patient underwent a total thyroidectomy. With current evidence-based guidelines lacking, we discussed some of the issues relevant to the surgical planning and postoperative management of such a patient.

Gastrointestinal Stromal Tumor of the Esophagus

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms that account for 0.2% of all GI neoplasms. We report a case of a 62-year-old male with a large esophageal GIST, and discuss the pathophysiology of the disease and the current management principles. This case is noteworthy because it documents a rare lesion in the esophagus that presents like other neoplastic diseases in this organ that usually carry a poor prognosis. An aggressive approach (e.g., more radical surgery, radiotherapy, and chemotherapy) might have been pondered based purely on the size of the lesion in this patient. It is important that primary care physicians and surgeons be aware of the possibility of the presence of this potentially curable lesion so as to avoid overtreatment.