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.

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

RESULTS

There 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.

Complications of ERCP for choledocholithiasis in a sickle cell cohort

Background

Patients with sickle cell disease (SCD) demand special attention during clinical interventions because they are predisposed to acute chest syndrome (ACS), vaso-occlusive crises, intra-vascular haemolysis and immune paresis. Although SCD is endemic in the Caribbean, there has been no report on endoscopic retrograde cholangio-pancreatography (ERCP) outcomes in these patients from this region.

Study

The records of patients with SCD who underwent ERCP between 1 January 2005 and 1 June 2010 were analysed retrospectively. Parameters assessed included patient demographics, procedural details, ERCP-related and SCD-related morbidity. Data were analysed using SPSS version 12.0.

Results

Fifty-four patients with SCD were subjected to ERCP during the study period. There were 37 women and 17 men at a mean age of 28 years (SD +/−12.05). There was 29% (16) overall morbidity, with 10 (18.5%) SCD-related complications and six (11.1%) ERCP-specific complications. More common complications were: pancreatitis (9.3%); cholangitis (1.9%); ACS (9.3%); pneumonia (3.7%); and painful crises (5.6%). There was one death (1.9%) due to multiple organ failure secondary to severe pancreatitis.

Conclusions

This study suggests that the SCD cohort requires special perioperative attention to minimise the inordinately high morbidity, many of which are SCD-related. We propose a perioperative management protocol that may minimise morbidity in these patients.

Clinical outcomes of single incision laparoscopic cholecystectomy in the anglophone Caribbean: a multi centre audit of regional hospitals

INTRODUCTION

There has been no report on Single-Incision Laparoscopic Surgery (SILS) cholecystectomy outcomes since it was first performed in the Anglophone Caribbean in 2009.

METHODS

A retrospective audit evaluated the clinical outcomes of SILS cholecystectomies at regional hospitals in the 17 Anglophone Caribbean countries. Any cholecystectomy using a laparoscopic approach in which all instruments were passed through one access incision was considered a SILS cholecystectomy. The following data were collected: patient demographics, indications for operation, intraoperative details, surgeon details, surgical techniques, specialized equipment, conversions, morbidity and mortality. Descriptive statistics were generated using SPSS 12.0.

RESULTS

There were 85 SILS cholecystectomies in women at a mean age of 37.4 ± 8.5 years with a mean BMI of 30.9 ± 2.8. There were 59 elective and 26 emergent cases. Specialized access platforms were used in the first 35 cases and reusable instruments were passed directly across fascia in the latter 50 cases. The mean operative time was 62.9 ± 17.9 minutes. There was no mortality, 2 conversions to multi-trocar laparoscopy and 5 minor complications. Ambulatory procedures were performed in 43/71 (60.6%) patients scheduled for elective operations.

CONCLUSION

In the Caribbean setting, SILS cholecystectomy is a feasible and safe alternative to conventional multi-trocar laparoscopic cholecystectomy for gallbladder disease.

Is emergent laparoscopic cholecystectomy for acute cholecystitis safe in a low volume resource poor setting?

BACKGROUND

The outcomes of emergent laparoscopic cholecystectomy (LC) for acute cholecystitis have not been documented in the low-volume, resource-poor Caribbean setting.

SETTINGS AND DESIGN

This study was carried out in a low-resource setting across three islands in the Anglophone Caribbean.

METHODS AND MATERIALS

The records of all consecutive patients who had emergency LC for acute cholecystitis over 82 months were examined. The data were extracted and analysed using SPSS version 14.

RESULTS

There were 74 patients with acute cholecystitis at a mean age of 45 (SD 11.8) years. The mean duration of operation was 99 (SD 45) min. There were 3 (4.1%) conversions and 6 (8.1%) complications. No bile duct injuries or deaths were recorded. There was more morbidity in patients with complicated disease, longer mean operation times and longer mean intervals between admission and operation.

CONCLUSIONS

Emergent LC for acute cholecystitis is effective and safe in a low-volume setting in the Caribbean. However, the operations are technically demanding and should be performed by trained laparoscopic surgeons.

Overcoming obstacles to establish a multidisciplinary team approach to hepatobiliary diseases: a working model in a Caribbean setting

Introduction

By providing a structured forum to exchange information and ideas, multidisciplinary team meetings improve working relationships, expedite investigations, promote evidence-based treatment, and ultimately improve clinical outcomes.

Methods

This discursive paper reports the introduction of a multidisciplinary team approach to manage hepatobiliary diseases in Jamaica, focusing on the challenges encountered and the methods used to overcome these obstacles.

Conclusion

Despite multiple challenges in resource-limited environments, a multidisciplinary team approach can be incorporated into clinical practice in developing nations. Policy makers should make it a priority to support clinical, operational, and governance aspects of the multidisciplinary teams.

Laparoscopic Inguinal Hernia Repair in a Developing Nation: Short-term Outcomes in 103 Consecutive Procedures

Background:

There are no published data on the outcomes of inguinal hernia repair from the Anglophone Caribbean. To the best of our knowledge, this is the first report of a series of laparoscopic inguinal hernia repairs from the region.

Materials and Methods:

Data was extracted from a prospectively maintained database of consecutive trans abdominal pre-peritoneal (TAPP) repairs done between June 1, 2005 and May 30, 2012. Perioperative data collected included patient demographics, hernia type, operative technique, duration of surgery, intra-operative details, morbidity, analgesia requirements, and duration of hospitalization. A telephone survey was also performed to identify late recurrences and complications. Descriptive statistics were generated using Statistical Package for Social Sciences (SPSS) Ver 12.0.

Results:

There were 103 consecutive TAPP procedures in 88 patients at an average age of 35.4 years ± 12.9 (standard deviation; SD) and average body mass index (BMI) of 28.9 Kg/m² ± 2.23 (SD). The indications were bilateral (30), recurrent unilateral (24), and primary unilateral (49) inguinal hernias. The mean duration of operation was 68.5 minutes (SD ± 10.4; Range: 55-95; Median 65; Mode 65) minutes for unilateral TAPP and 89 minutes (SD ± 7.61; Range: 80-105; Median 90; Mode 90) for bilateral repairs. Post-operatively, 65/70 patients required ≤1 dose of parenteral opioid analgesia and 74 (84.1%) patients discontinued oral analgesia within 48 hours of operation. Complications were recorded in six (5.8%) cases and a recurrence in one (0.97%) case after a mean follow-up period of 3.2 years (SD ± 1.8; Range: 0.5-7).

Conclusion:

Laparoscopic inguinal hernia repair is a safe and effective operation in this setting.

Duodenal fibrosarcoma mimicking Franz tumour complicated by post-resection chylous ascites

This case report presents a young woman who underwent a Whipples resection for a large pan-creato-duodenal tumour. Pathology and immunohistochemical analysis of the tumour suggest duodenal fibrosarcoma. The patient's postoperative management was complicated by chylous ascites. A brief literature review is given to highlight this unusual case.