Laparoscopic liver resections require advanced laparoscopic skill sets. In the Caribbean, a unique situation exists where centers of excellence for liver resections exist, but surgeons who are trained in advanced laparoscopic surgery are not available throughout the region. Therefore, many patients who are candidates for liver resection in the Caribbean do not have the opportunity to receive laparoscopic operations. We report a case of distance mentoring using readily available, inexpensive equipment to complete a laparoscopic liver resection, mentored by an expert hepatobiliary surgeon. It may be considered, in special cases, as a way to increase the availability of laparoscopic operations. We acknowledge that there are many limitations to the use of this technology and we discuss the pros and cons of distance mentoring for this purpose.

Barbados is an island in the Eastern Caribbean that is reported to have the 8th highest incidence of colorectal cancer (CRC) worldwide. However, these figures are based only on estimates, and there is little available epidemiological data collected from Barbadians with CRC. The present study sought to collect epidemiologic data from patients in Barbados diagnosed with CRC. This information is considered important to shape national public health policies. For this purpose, hospital admission registers at all tertiary care facilities in Barbados were retrospectively audited over a four-year period from January 1, 2014 to December 31, 2018 to identify patients who underwent operative treatment for CRC. The following data were extracted: Age, sex, ethnicity, the location of the primary tumour and tumour stage. Descriptive statistical analyses were generated using SPSS version 21.0. The results revealed that there were 97 patients with CRC at a mean age of 64.9 years (SD ±12.2) and a male preponderance (1.3:1). The majority (93.8%) were from the African diaspora. Only 18.5% of diagnoses were made at (opportunistic) screening. Consequently, two thirds of the patients had advanced-stage disease at diagnosis. The disease staging of the patients was as follows: Stage 0 (1%), stage I (10.3%), stage II (23.7%), stage III (38.1%) and stage IV (26.8%). Right-sided primary tumours were most common (44.3%), followed by left-sided (41.2%) and rectal lesions (14.4%). Women were significantly more likely to have right-sided lesions (55 vs. 45%) and males were more likely to have rectal lesions (77 vs. 23%). On the whole, the present study highlights the need to implement a national screening programme in this high-risk population of African origin with a predominantly right-sided distribution of CRC primary tumours. This is reinforced by the fact that 10% of patients will be diagnosed before the age of 50 years with more aggressive disease.

Introduction and importance Altemeier rectosigmoidectomy has been cited in the literature as a suitable approach for incarcerated rectal prolapse when a large segment of bowel is involved. However, the literature is devoid of cases that employed the technique as an oncological procedure for rectal carcinoma. For this reason, this case report heralds a new perspective on an old technique. Case presentation We describe the case of a male in his 6th decade who presented with stage four rectal cancer. Computed tomography imaging showed a rectal mass at the rectosigmoid junction with pelvic lymphadenopathy and a solitary hepatic lesion in segment two of the liver. While admitted to the hospital a 16 cm segment of bowel containing the mass prolapsed and became incarcerated, eventually becoming necrotic. A modification of the Altemeier procedure was performed along with a diverting ileostomy and hepatic wedge resection of the solitary metastases. Histological assessment of the surgical specimens confirmed that adequate resection margins were obtained with one of twenty-one lymph nodes positive for malignancy. He is currently being followed up in the outpatient oncology clinic and has commenced adjuvant chemotherapy. Clinical discussion Synchronous excision of rectal carcinoma with hepatic metastasectomy is a feasible surgery even in the emergency setting and can offer improved patient survival. Conclusion The combination of both an abdominal and perineal approach was suitable for this patient given his improved quality of life and negative pathological margins.

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Background: Fast track protocols (FTPs) have triggered considerable improvements in patients’ perioperative care and are accepted as the standardised approach to patient management in developed countries globally. Although the benefits of FTPs have been illustrated for some time, they are not universally used in developing countries. In the Eastern Caribbean, FTPs are implemented in an ad-hoc manner based on the attending surgeons. Methods: We designed a comprehensive FTP modified for use in Barbados, an island nation in the Eastern Caribbean. After consensus, the FTPs were introduced into clinical practice at a tertiary referral public hospital. We prospectively evaluated clinical outcomes after introduction of FTP protocols for all patients undergoing colorectal operations from January 1, 2018 to February 1, 2019. The study population was divided into three groups: Group I: full adherence (>16 FTP steps completed), Group II: partial adherence (10-15 FTP steps completed), Group III: non-adherence to FTP protocols (<9 FTP steps observed). In each group, we compared morbidity, mortality, return of bowel function, length of post-operative hospital stay and hospital readmission using SPSS version 20 for statistical analyses.  Results: Over the study period, there were 27 colorectal operations performed. When the outcomes in group 1 and group 3 were compared, there was a statistically significant reduction in post-operative LOS (3 Vs 8.9 days; P<0.05) and overall morbidity (10% vs 50%; P 0.05) in the full FTP adherence groups. Conclusions: In this Caribbean healthcare system, FTP implementation resulted in significant improvements in post-operative duration of hospitalization and overall morbidity. The main challenge is to achieve universal buy-in from health care providers in the Caribbean. We believe that the way to achieve this is continued medical education and targeted research to acquire local practice data from the Caribbean. We advocate the incorporation of FTP into colorectal surgical practice for Caribbean hospitals.