Nigel Bascombe

Associations among ancestry, geography and breast cancer incidence, mortality, and survival in Trinidad and Tobago

Breast cancer (BC) is the most common newly diagnosed cancer among women in Trinidad and Tobago (TT) and BC mortality rates are among the highest in the world. Globally, racial/ethnic trends in BC incidence, mortality and survival have been reported. However, such investigations have not been conducted in TT, which has been noted for its rich diversity. In this study, we investigated associations among ancestry, geography and BC incidence, mortality and survival in TT. Data on 3767 incident BC cases, reported to the National Cancer Registry of TT, from 1995 to 2007, were analyzed in this study. Women of African ancestry had significantly higher BC incidence and mortality rates (Incidence: 66.96; Mortality: 30.82 per 100,000) compared to women of East Indian (Incidence: 41.04, Mortality: 14.19 per 100,000) or mixed ancestry (Incidence: 36.72, Mortality: 13.80 per 100,000). Geographically, women residing in the North West Regional Health Authority (RHA) catchment area followed by the North Central RHA exhibited the highest incidence and mortality rates. Notable ancestral differences in survival were also observed. Women of East Indian and mixed ancestry experienced significantly longer survival than those of African ancestry. Differences in survival by geography were not observed. In TT, ancestry and geographical residence seem to be strong predictors of BC incidence and mortality rates. Additionally, disparities in survival by ancestry were found. These data should be considered in the design and implementation of strategies to reduce BC incidence and mortality rates in TT.

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.

Laparoscopic Diverticulectomy for Massive Hemorrhage in a Duodenal Diverticulum

Hemorrhagic duodenal diverticula are rare and are treated by endoscopy or open diverticulectomy, especially when there is a massive hemorrhage. We report what we believe to be the first instance of urgent laparoscopic diverticulectomy of a large, inflamed duodenal diverticulum with massive hemorrhage. An elderly patient had a screening colonoscopy and additional upper gastrointestinal endoscopy because of vague upper gastrointestinal symptoms; however, both were reported to be normal. She subsequently developed massive hematemesis. Clinical examination revealed a tender right upper quadrant mass and imaging confirmed a large duodenal diverticulum with surrounding inflammatory changes. Urgent laparoscopic diverticulectomy was performed with an uneventful recovery and follow-up. Laparoscopic diverticulectomy should be considered in managing hemorrhagic duodenal diverticula.

A case report of the clear cell variant of gallbladder carcinoma

Highlights • Patient history and clinical findings are often not specific enough to arrive at a diagnosis of clear cell gallbladder carcinoma.• Consideration of morphologic and immunophenotypic features are essential to establish a diagnosis of clear cell gallbladder carcinoma.• It is important for clinicians to differentiate gallbladder cancer from metastases that most commonly arise from the kidneys and other possible secondary foci.

Minimally Invasive Surgery in the Management of Adhesive Small Bowel Obstruction: A Rare Case

Introduction: We present the management of a patient who failed conservative management of adhesive small bowel obstruction (ASBO), which was treated with laparoscopic lysis of adhesions. Presentation of Case: A 66 year old, hypertensive, diabetic patient with previous gynaecological surgery presents with symptoms of intestinal obstruction for 2 days. Clinical & radiological features are consistent with the diagnosis of SBO. Conservative treatment was started but the patient failed to show any signs of resolution. Laparoscopic adhesiolysis was successfully performed on thin adhesions between the liver and the anterior abdominal wall (possible Fitz-Hugh Curtis syndrome), which trapped the small bowel. The patient was discharged on day 4 of admission. Discussion: ASBO is a very common and actual disease and its management deserves great attention. Although surgeons are hesitant to perform laparoscopy in patients with distended small bowel due to adhesive obstruction, laparoscopic surgery performed by experienced surgeons offers the opportunity of shorter hospital stay, quick recovery and less morbidity, including wound sepsis and incisional hernia when compared with laparotomy. Conclusion: Minimally invasive surgery (MIS) in ASBO is not standard of care, however, selected patients may benefit from the advantages of this approach. Once the necessary expertises are available, an attempt to treat these patients with MIS may be safe, and as such, should be entertained.

Laparoscopic resection of a retroperitoneal myolipoma presenting in a right inguinal hernia.

INTRODUCTION Myolipoma of soft tissue is an extremely rare benign lipomatous lesion. The lesions are most commonly located in the abdominal cavity, retroperitoneum, and inguinal areas. Despite their large size, myolipomas are cured by surgical resection. PRESENTATION OF CASE We present the case of a 79 year-old man who presented with bilateral reducible inguinal hernias (right larger than left). After reducing the right inguinal hernia (RIH), the sensation of a palpable mass was noted in the right iliac fossa. CT scan suggested the content of the right inguinal hernia (RIH) to be small bowel mesentery and no other mass was noted in the right iliac fossa (possibly missed on CT scan). DISCUSSION A very large 1.8kg retroperitoneal lipomatous lesion, measuring 22cm×16cm×8cm, attached to the right spermatic cord was found and excised laparoscopically during a trans-abdominal pre-peritoneal (TAPP) approach to repair the hernias. The lesion was pathologically defined as a myolipoma. CONCLUSION The laparoscopic TAPP approach to repair inguinal hernias allows the surgeon to inspect the peritoneal cavity, and in this case it was possible to safely dissect and remove a large, lipomatous, retroperitoneal lesion laparoscopically. To the best of our knowledge, there are no reports of local recurrence, metastatic disease, or malignant transformation of myolipomas, and the laparoscopic approach to resect such a lesion has not been reported.

Cancer incidence and mortality rates and trends in Trinidad and Tobago

BackgroundCancer is the second leading cause of death in the Caribbean, including the islands of Trinidad and Tobago (TT). The population of TT consists of over 1.3 million people with diverse ancestral and sociocultural backgrounds, both of which may influence cancer incidence and mortality. The objective of this study was to examine incidence and mortality patterns and trends in TT.MethodsCancer surveillance data on 29,512 incident cancer cases reported to the Dr. Elizabeth Quamina Cancer Registry (population-based cancer registry of TT) between 1995 and 2009 were analyzed. Age-standardized rates, overall and by sex, ancestry, and geography, were reported.ResultsThe highest incidence and mortality rates were observed for cancers related to reproductive organs in women, namely, breast, cervical, and uterine cancers, and prostate, lung and colorectal cancers among men. Average incidence rates were highest in areas covered by the Tobago Regional Health Authority (TRHA) (188 per 100,000), while average mortality rates were highest in areas covered by the North West Regional Health Authority (108 per 100,000). Nationals of African ancestry exhibited the highest rates of cancer incidence (243 per 100,000) and mortality (156 per 100,000) compared to their counterparts who were of East Indian (incidence, 125 per 100,000; mortality, 66 per 100,000) or mixed ancestry (incidence, 119 per 100,000; mortality, 66 per 100,000).ConclusionsOur findings highlight the need for national investment to improve the understanding of the epidemiology of cancer in Trinidad and Tobago, and to ultimately guide much needed cancer prevention and control initiatives in the near future.

Minimally Invasive Surgery for Small Bowel Obstruction: The Experience of a Tertiary Hospital in the Anglo-Caribbean

Objectives: The aim of this study was to access the feasibility and benefit of minimally invasive surgery for Small Bowel Obstruction in a tertiary hospital in Trinidad and Tobago. Design and Methods: All patients with clinical and radiologically diagnosed small bowel obstruction, who had nil resolution with conservative management at 48 hours, or who had nil passage of oral contrast into the colon at 12 hours, were included in this case series. Exclusion criteria included: anesthesiological contraindication for laparoscopy. The primary endpoints were resolution of obstruction (time to first bowel movement, time to commencement of oral feeds) and length of hospital stay. Secondary endpoints included overall morbidity and operative complications (bleeding, subphrenic or pelvic intraabdominal abscesses, wound infections, respiratory complications), during and after hospitalisation. Results: There were five (5) patients who meet the inclusion criteria for this case series from January 2014 to March 2015. 40% (2/5) of the patients were female. The mean age was 38.4 yrs. Conversion rate was 0%. The enterotomy rate was 20% (1/5). The median duration of postoperative ileus was 5 days. . The median duration of postoperative hospital stay was 5.6 days, mean time to enteral feeds was 1.8 days. Rate of post-operative complications was 20% (1/5). Conclusion: With appropriate patient selection, minimally invasive surgery is a safe alternative to open surgery for SBO, with acceptable morbidity and mortality.