Not just a simple inguinal hernia. A rare case of an inguino-scrotal ureter!

Inguinal hernias involving the ureter or inguino-scrotal ureters are a rare and infrequently described finding with both clinical and surgical consequence. While the majority are asymptomatic and rarely cause obstructive uropathy our case aptly highlights the risk to a general surgeon prior to an elective hernia repair. A review of the literature outlines a systematic approach of investigation if clinical suspicion of an inguino-scrotal ureter is raised, with careful operative planning and a multidiscipline approach for repair recommended.

Immediate Two-Stage Prosthetic Breast Reconstruction Failure: Radiation Is Not the Only Culprit.

BACKGROUND: Immediate prosthetic breast reconstruction produces a satisfactory aesthetic result with high levels of patient satisfaction. However, with the broader indication for postmastectomy adjuvant radiation therapy, many patients are advised against immediate breast reconstruction because of concerns of implant loss and infection, particularly as most patients also require chemotherapy. This retrospective cohort study examines outcomes for patients who underwent immediate two-stage prosthetic breast reconstruction after mastectomy with or without adjuvant chemotherapy or radiotherapy. METHODS: Between 1998 and 2010, 452 patients undergoing immediate two-stage prosthetic breast reconstruction involving a total of 562 breasts were included in this study. Stage 1 was defined as insertion of the temporary expander, and stage 2 was defined as insertion of the final silicone implant. Postoperative adjuvant radiotherapy was recommended with a tissue expander in situ for 114 patients. Complications, including loss of prosthesis, seroma, and infection, were recorded and analyzed. Cosmetic result was assessed using a four-point scale. RESULTS: Postoperative prosthesis loss was 2.7 percent, 5.3 percent for patients undergoing adjuvant chemotherapy and increasing to 11.3 percent for patients receiving chemotherapy plus radiotherapy. Chemotherapy and radiotherapy independently were the main, statistically significant risk factors for expander or implant loss [incidence rate ratio, 13.85 (p = 0.012) and 2.23 (p = 0.027), respectively]. Prosthesis loss for patients undergoing combination chemotherapy plus radiotherapy was also significant [incidence rate ratio, 4.791 (p < 0.001)]. CONCLUSIONS: These findings serve to better inform patients on risk in weighing treatment options. Postmastectomy radiation therapy doubles the risk of prosthesis loss over and above adjuvant chemotherapy but is an acceptable option following immediate two-stage prosthetic breast reconstruction in a multidisciplinary setting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Immediate and Long-term Complications of Direct-to-implant Breast Reconstruction after Nipple- or Skin-sparing Mastectomy.

BACKGROUND: Traditionally, breast reconstruction options after mastectomy comprise an autologous flap or staged expander/implant reconstruction, or a combination of both. Recent introduction of skin or nipple-sparing mastectomies have led to much interest in direct-to-implant immediate breast reconstructions. We performed a retrospective review of our initial experience. METHODS: Between June 1998 and December 2010, 31 of 671 patients (4.6%) who received implant-only breast reconstruction underwent direct-to-implant immediate breast reconstruction after mastectomy for primary or recurrent cancers, or risk reduction. Their files were audited, and the primary factor examined was the failure of reconstruction with loss of prosthesis. Other complications, revision surgery, and aesthetic result are also recorded. RESULTS: The mean follow-up period for the 31 patients was 49.5 months. A total of 45 mastectomies were performed for 21 primary and 4 recurrent breast cancers after previous conservation surgery and radiotherapy (RT), and 20 for risk reduction. Ten patients received RT (4 before mastectomy and 6 afterward). Average size of implants was 380.0 g (range, 205-620 g). The most common postoperative complications were seromas (20%); only 1 implant was lost (2.22%). Nineteen breasts required revision surgery after 6 months with 1 more implant lost. Despite the high revision rate, 28 (90.3%) had excellent or good aesthetic result. CONCLUSIONS: Immediate single-stage direct-to-implant breast reconstruction has a high rate of both immediate postoperative complications and revisions after 6 months, especially after RT. However, most complications are manageable and do not necessarily result in implant loss. Most cases can have a successful outcome without implant loss with excellent or good cosmetic results.

Two-Stage Prosthetic Breast Reconstruction after Mastectomy with or without Prior Postmastectomy Radiotherapy.

BACKGROUND: Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by an implant after a period of inflation is a well-established breast reconstruction option. Most of the current literature concentrates on the immediate setting, and there are only a few reports into delayed cases, especially after postmastectomy radiotherapy (RT). We performed a retrospective review of our experience over a 12.5-year period. METHODS: Between June 1998 and December 2010, a total of 671 patients received prosthetic-only breast reconstruction. Of these, 170 (25.3%) underwent delayed 2-stage prosthetic breast reconstruction after mastectomy for cancer. Patients were divided into group A, no postmastectomy RT (n = 150), and group B, postmastectomy RT (n = 20). The primary factor examined was the failure of the reconstruction from loss of prosthesis with or without smoking. Other complications, as well as rates of revisional surgery were also recorded. RESULTS: Expander or implant loss occurred in 3 of 150 patients in group A (2.0%) and 3 of 20 patients in group B (15%; P = 0.02). For nonsmokers, implant loss was 1.6% and 5.6%, respectively (P = NS). Smoking was associated with 1 of the 3 losses in group A and 2 of the 3 in group B (smokers, n = 2; P < 0.01). There was no significant difference in other complications such as seromas or minor wound infections. CONCLUSIONS: Delayed 2-stage prosthetic breast reconstruction has a low failure rate. It can also be successfully completed in selected patients after postmastectomy RT, but care must be taken with patients who smoke.

Breast Augmentation after Conservation Surgery and Radiation Therapy.

BACKGROUND: There is a paucity of data regarding outcomes for patients undergoing breast augmentation with implants after breast conservation surgery (BCS) and radiotherapy. This retrospective study examined outcomes for patients with breast implant-only augmentation after BCS and radiotherapy. METHODS: Between June 1998 and December 2010, 671 women underwent prosthetic breast reconstruction. Nineteen patients (2.8%) underwent an augmentation after BCS and radiotherapy. The mean age was 55.8 years (range, 40-69 years). Sixteen of these patients underwent one-stage implant-only breast augmentation, whereas 3 patients underwent two-stage expander and then implant augmentation. RESULTS: All surgeries were successful. The average size of breast implant used was 258.7 g. Seven patients also received contralateral augmentation with an average implant size of 232.2 g. One patient received oral antibiotics for minor wound infection. Patients were judged to have an excellent (14/19; 73.7%), good (3/19; 15.8%), or fair (2/19; 10.5%) cosmetic result. CONCLUSION: The breasts of selected patients with breast cancer after BCS and radiotherapy. with asymmetry can be adequately augmented with breast implants alone.

A rare gallbladder ciliated foregut cyst in chronic cholecystitis.

INTRODUCTION: Ciliated foregut cysts (CFC) are rare anomalies due to aberrant embryological development. It is thought to arise from a remnant of the embryologic foregut. The solitary cysts are characterised by ciliated pseudostratified columnar epithelium. They are usually located above the diaphragm but they can also arise in relation to the liver, gallbladder and pancreas. PRESENTATION OF CASE: We present the first ciliated foregut cyst of the gallbladder case reported in Australia, and the ninth known case to be reported worldwide. A 61-year-old male with chronic cholecystitis and cholelithiasis underwent an elective laparoscopic cholecystectomy and intraoperative cholangiogram. Intraoperatively, 'out-pouching' was noted on the lateral border of the gallbladder. Microscopically the histopathology showed that the cyst was lined by ciliated columnar epithelium the characteristic feature of a ciliated foregut cyst. DISCUSSION: To date only 8 cases of these ciliated foregut cysts in the gallbladder have been reported in literature. Our case is the first reported in Australia. It is unique in that the patient was an older male as opposed to most other previous cases, which were younger females. These cysts can be difficult to distinguish from neoplasms clinically and radiographically. Reports have shown that these cysts may become dysplastic and is best excised when discovered. CONCLUSION: Despite the rarity of CFCs and their potential to mimic malignancy, we propose awareness and understanding of the management for them-being excision and hopefully not cause any confusion or devastatingly allow it to become malignant.

Comparación entre la Escala de Evaluación Cognitiva en Esquizofrenia (SCORS) y la Escala de Inteligencia de Wechsler (WAIS) en pacientes esquizofrénicos del Hospital Hipólito Unanue / Comparison between the Cognitive Assessment Scale in schizophrenia (SCORS) and the Wechsler Intelligence Scale (WAIS) in schizophrenic patients at the Hospital Hipolito Unanue

Objetivo: Determinar el grado de correlación que existe entre la aplicación del SCoRS y la valoración cognitiva realizada a través del WAIS en el Hospital Nacional Hipólito Unanue. Metodología: Se realizó un estudio observacional, analítico, y de corte transversal. Se revisaron las historias clínicas de pacientes atendidos en el Servicio de Psiquiatría del Hospital Hipólito Unanue con diagnóstico principal de esquizofrenia entre los meses de Enero a Abril en el año 2011. Resultados: Se vieron un total de 24 casos, siendo la media de edad 33,50±13,433, de igual forma se evaluó el tiempo de enfermedad, encontrándose una media de 10±8,572 años; predominó el sexo masculino (62,5 por ciento) y el medicamento más utilizado la risperidona. Se calculó el coeficiente Alfa de Cronbach para las variantes del SCoRS, obteniéndose un valor de 0,917, 0,939, 0968 para el SCoRS paciente, familiar y evaluador respectivamente. Por otro lado, el análisis factorial reveló 6 dimensiones para el SCoRS paciente, 4 dimensiones para SCoRS familiar y 4 dimensiones para el SCoRS evaluador. El análisis de correlación de Pearson mostró una relación inversamente proporcional en las tres variantes del SCoRS estudiadas frente al WAIS verbal, ejecutivo y el Coeficiente Intelectual. Sin embargo, el SCoRS del familiar mostró un valor P<0,001 frente a las tres variantes del WAIS. Además se encontró una buena aceptabilidad y tolerabilidad por parte de los evaluados. Conclusiones: El SCoRS es una prueba confiable y válida en comparación con el WAIS, con buena aceptabilidad y tolerabilidad por parte de los evaluados.

Objective: To determine the correlation degree between the application of the SCoRS and the cognitive assessment made through the WAIS in the National Hospital Hipolito Unanue. Methodology: An observational, analytic and transversal study was realized. Were reviewed medical records of the patients, treated at the Department of Psychiatry of Hipolito Unanue Hospital, with a diagnosis of schizophrenia between the months January to April in the year 2011. Results: They were a total of 24 cases, with a mea n age 33.50±13.433 and the mean time of disease in 10±8.572 years. Most were males (62.5 per cent), and the drug that was more used was risperidone. It was calculated the coeficient Alpha of Cronbach for variants of SCoRS, obtaining a value of 0.917, 0.939, 0.968 for SCoRS patient, family and evaluator, respectively. In the same way it was made the factorial analysis, as result there were 6 dimensions for patient SCoRS, 4 dimensions for familiar SCoRS and 4 dimensions for evaluator SCoRS. The Pearson correlation analysis showed a proportionally inverse relation in the three variants studied SCoRS against WAIS verbal, executive and la. However, familiar SCoRS shows a value of P<0.001 versus the three variants of WAIS. Also found good acceptability and tolerability by evaluated. Conclusions: The SCoRS is a reliable and valid test compared with WAIS, It has good acceptability and tolerability by evaluated.