Modified surgical technique for treatment of high-grade gynecomastia: a preliminary study

This study was designed to evaluate the outcome of a modified surgical approach for management of Simon's II and III gynecomastia. Fourteen patients with idiopathic gynecomastia [9 unilateral and 5 bilateral] were enrolled in the study. A preareolar incision was performed at the upper half of the areolar-cutaneous line, then another curved incision was made cephalad to the first incision and was extended so as both ends of both incision met and thus giving a picture of an elliptical incision with the width of the ellipse varied according to the surface area of skin determined, preoperatively, to be excised. All fibrofatty tissue was dissected and excised and surgical field was drained. The surgical procedure was completed straightforward without intraoperative problems with a mean duration of surgery being 35 for unilateral and 56 minutes for bilateral cases. Suction drains were removed after 4-5 days in most patients. One month after surgery, all patients had achieved a good aesthetic contour of the chest and were satisfied, but as regards wound appearance, 3 patents were partially satisfied: 2 patients had excess wound edge [dog-ear] that re-corrected under local anesthesia and one patient has bilaterally corrugated scar, and only one patient was unsatisfied by the color of the areola and nipple. It could be concluded that the use of a semicircular incision placed at the upper areolar-cutaneous junction combined with a cephalad positioned curved incision is a good approach for the treatment of high-grade gynecomastia allowed excellent access for glandular excision with preservation of quite sufficient blood supply to the nipple-areola complex, with unapparent preareolar scar and symmetrical non-ptosed areola or nipple

Diagnostic accuracy of combined clinical, ultrasonography and fine needle aspiration cytology for thyroid swelling assessment

The present study was designed to evaluate applicability of combination of clinical examination, neck conventional ultrasonography [US] and US-guided fine needle aspiration cytology [FNAC] as a strategy for assessment of thyroid swellings and differentiating between malignant and benign thyroid lesions. The study included 50 patients [5 males and 45 males with a mean age of 37.1+/-6.9 years] with nodular thyroid swelling. All patients underwent complete history taking, full clinical examination, neck US and US-guided FNAC. All patients underwent thyroidectomy and excised specimens were examined histopathologically. All patients passed smooth intra- and postoperative course apart from 4 cases that developed postoperative hematoma collection, one of them required evacuation. Histopathological examination defined 5 [10016] papilary and one [2%] follicular carcinoma and 44 [88%] benign nodules. Clinical examination detected 14 patients [28%] with criteria of suspicious malignancy while the other 36 patients showed no criteria of suspicious malignancy. Clinical diagnosis could define malignant thyroid lesions with sensitivity 66.7%, specificity 77.3% and accuracy 76%. The receiver operating characteristic [ROC] curve analysis for the diagnostic yield of clinical findings for differentiating between malignant and benign thyroid as judged by the area under the curve [AUC] showed AUC=0.652. Conventional US diagnosis depending on US signs of malignancy revealed that 2 malignant lesions were solid, hypoechoic nodules with blurred margins, no halo sign and with fine calcification, another 2 malignant nodules were solid, isoechoic nodules with blurred margins, no halo sign and with coarse calcification, whereas the remaining 2 malignant nodules were solid, hypoechoic nodules with well-defined margins, present halo sign and with coarse calcification, ROC curve analysis for the diagnostic yield of each US finding separately showed that presence of fine calcification had the highest diagnostic yield [AUC=0. 739], presence of blurred margin and absent halo sign [AUC=0. 72], internal echogenecity [AUC=0.667] and echostructure [AUC=0.527]. Fine needle aspiration was carried out successfully in 48 patients with a success rate of 96% and diagnosed 4 specimens as papillary carcinoma, 5 as follicular neoplasm and 39 specimens as hyperplastic nodules. FNAC could diagnose malignancy with sensitivity 83.3%, specificity 90.5% and accuracy rate of 89.6% and ROC curve analysis for the diagnostic yield of FNAC showed AUC=0.871. It could be concluded that the combined dependence on clinical judgment, the result of US-guided FNAC and the presence of blurred margin of the nodule associated with absence of Halo sign and micro-calcification using conventional neck US provided the most significant diagnostic yield for differentiating between malignant and benign thyroid lesions

Feasibility of combined laparoscopic cholecystectomy and anti-reflux surgery: evaluation and outcome

This study was designed to evaluate the outcome of combined laparoscopic cholecystectomy and fundoplication during one single laparoscopic procedure. The study included only patients assigned to undergo cholecystectomy for calcular cholecystitis and had symptomatic gastroesophageal reflux disease [GERD], 22 patients [7 males and 15 females] were enrolled in the study. All patients underwent clinical history taking including duration of symptoms, physical examination and upper gastrointestinal endoscopy. Esophageal manometry was performed preoperatively and 2 and 6 months after surgery. Laparoscopic procedures were performed through 5-port access. Operative time and the frequency of conversion to open surgery, time till initiation of oral intake, postoperative hospital stay and complications and time to recover full activity were recorded. Through a monthly visit for 6 months after surgery, patients were monitored for the extent of resolution of GERD-related symptoms. There was a significant increase [p<0.001] of postoperative lower esophageal sphincter [LES] pressure compared to preoperative pressure with a non-significant difference between pressures estimated at 2 and 6 months. No intraoperative complications were encountered and there was no need for conversion to open surgery in any case. The mean operative time was 78.3+/-9.7; range: 60-90 minutes. All patients tolerated oral ingestions after the first 48 hours. The mean duration of postoperative hospital stay was 4+/-0.8; range: 3-5 days and 9 patients [40.9%] were discharged on the 3[rd] postoperative day. The mean duration till resumption of full daily activities was 11.6+1.4 [10-14] days. Clinically, a marked resolution of symptoms due to reflux was observed, only one patient developed dysphagia for solid food and a sensation of trapped air occurred in two patients causing discomfort, however, these three patients were asymptomatic at 6 months after the surgery. It could be concluded that combined laparoscopic surgery for cholelithiasis and GERD is an appropriate procedure, when indicated, giving excellent short-term outcome results and could be managed during one single laparoscopic procedure

One-stage primary ileo-colic or ileo-rectal anastomosis. For acute malignant left colonic obstruction

The aim of this study was to evaluate the immediate and short-terme follow-up results of one-stage subtotal or total colectomy and anastomosis for patients with malignant left colon obstruction. The study comprised 21 patients [10 males and 11 females] with age range of 36-81 years; presented by acute large bowel obstruction with clinical and radiological evidence of obstruction. The choice of the extent of resection was determined by the extent of fecal load, the presence of colonic perforation, serosal tears of the cecum and/or massive colonic distension with concomitant ischemia: the presence of these features in a hemodynamically stable patient favored subtotal or total colectomy and ileo-colic or ileo-rectal anastomosis. The site of obstruction was at the sigmoid colon in 9 patients [42.9%], rectosigmoid in 8 patients [38.1%], splenic flexure in 3 patients [14.3%] and descending colon in one patient [4.7%]. Ileosigmoid anastomoses were done in 13 patients [61.9%] and 8 patients [38.1%] had ileorectal anastomoses. The mean operative time was 201+/-33.2; range: 150-270 minutes, the mean operative blood loss was 633.3+/-408.2; range: 250-1800 cc; 11 patients [45.8%] required blood transfusion with a mean number of blood bags used was 2.8+/-1.2; 1-5 bags. Oral feeding was resumed after a mean period of 4.9+/-0.9; range: 4-7 days and the mean postoperative hospital stay was 10+/-2.2; range: 8-18 days. Overall, after 12-months follow-up only one patient had anastomotic line recurrence with a recurrence rate of 4.75%, one patients died of acute liver failure secondary to hepatic metastasis with mortality rate of 4.75% and 19 patients had follow-up free of morbidity with no-local recurrence or metastasis and a follow-up free rate of 90.5%. Thus, it could be concluded that one-stage subtotal or total colectomy and ileo-colic or ileo-rectal anastomosis are safe procedure with satisfactory outcome for management of obstructing malignant lesions of the left colon