Access to Breast Reconstruction in Kuwait: Assessing Surgeon-related Factors as a Barrier to Referral.

It is not uncommon for breast cancer patients to undergo a mastectomy without receiving or being presented with the option of having a breast reconstruction. With a low rate of breast reconstruction in Kuwait, we aim to assess physician-related factors as a barrier to referral. Methods: This is an online questionnaire-based study to investigate the variation in the referring general surgeons' knowledge and perception towards breast reconstructive surgery. Results: A total of 141 general surgeons responded to the questionnaire, and only 63 (44.7%) always discuss the available options for reconstruction with their breast cancer patients. When asked about referral to a plastic surgeon, only 49 (34.8%) responded with always, and the majority (N = 61; 43.3%) responded with sometimes. More than half (N = 73; 51.8%) believe that the general surgeon should determine patient suitability for referral to a plastic surgeon, while only 53 (37.6%) agree that breast cancer patients should always be referred to a plastic surgeon for consideration of reconstruction. The mean knowledge score was 6.6 of 8, while the mean perception score was 8.9 of 12. Responders with a higher total knowledge score were more likely to discuss with patients the availability of reconstruction. Conclusions: Despite the acceptable knowledge scores in our general surgeons, there is a low rate of referral for breast reconstruction in Kuwait. There is a pressing need to generate legislations and a streamlined protocol for referral that facilitate access to breast reconstructive services.

Intramuscular myxoma of the left thigh: A case report.

INTRODUCTION AND CLINICAL IMPORTANCE: Intramuscular myxoma (IM) is a rare benign soft tissue tumor that involves the musculoskeletal system with a reported incidence of 0.1-0.13 per 100,000. The mean age of diagnosis is 40-70 years of age, with female predilection. The most common site of involvement is the thigh, however, it may present in other areas such as the upper arm, calf, and buttock. CASE PRESENTATION: A case of a 45-year-old female without a significant past medical or surgical history who presented with 3-year history of a slow-growing, painless mass in her left upper thigh. MRI scan was performed which showed intramuscular soft tissue mass lesion 9 × 6 × 4.5 cm implicating the left distal vastus medialis muscle. A fine needle aspiration was inconclusive so a core needle biopsy was performed which was suggestive of intramuscular myxoma. A complete surgical excision of the mass was done and the postoperative period was uneventful and patient was discharged home. The final histopathological examination confirmed the diagnosis of intramuscular myxoma. DISCUSSION: Intramuscular myxoma is a rare benign soft tissue neoplasm. 50 % of cases commonly occur in the thigh. IM has an unknown etiology, however, the literature has showed common gene mutations such as the GNAS gene mutations (Guanine nucleotide binding protein, alpha stimulating). Imaging modalities such as ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) are useful in diagnosis of soft tissue mass but not specific to intramuscular myxoma. Histopathological examination is the gold standard for diagnosis. The treatment of choice is surgical excision with clear margins to prevent recurrence, which is extremely rare. CONCLUSION: Intramuscular myxomas, although benign and rare, should be in the differential diagnosis of soft tissue lesions due to the similarity they share with malignant tumors such as sarcomas. Histopathological examination is the gold standard for diagnosing a soft tissue lesion and surgical excision is the treatment of choice.

An unusual and life-threatening presentation of a large GIST.

INTRODUCTION: Gastrointestinal stromal tumours (GIST's) are rare tumours of the alimentary tract. They are often discovered incidentally during imaging or intra-operatively. In rare instances, they present acutely with life threatening gastrointestinal (GI) bleeding requiring emergency surgical intervention. CASE PRESENTATION: A 47-year-old gentleman, who is an ex-smoker with normal body mass index (BMI), presented with acute onset of epigastric pain, dizziness, and multiple episodes of melaena. The patient deteriorated rapidly and urgent endoscopy revealed active retrograde bleeding from beyond the duodenojejunal junction. Computed tomography angiography (CTA) suggested a highly vascular ileal exophytic mass resembling a GIST. Emergency exploratory laparotomy was conducted where hemostasis was achieved via segmental enterectomy of the mass that was unexpectedly jejunal in origin. During recovery, he encountered post-operative complications that were managed conservatively and eventually was discharged with a referral to the national cancer centre. CLINICAL DISCUSSION: The clinical presentation of GIST is based on its size and location. Definitive diagnosis of GIST relies on histopathological findings although the clinical presentation and imaging, in particular CTA, can aid in its diagnosis. Management of GIST differs depending on the clinical presentation, size, location and whether metastasis is present. Surgical resection is the standard of treatment; however, Imatinib could be used for non-resectable tumours as well as in cases of recurrence, metastasis or as an adjuvant chemotherapy. CONCLUSION: It is important to acknowledge that small GISTs are often asymptomatic while larger ones may present with non-specific symptoms which can be misleading. This could potentially delay the diagnosis and thus treatment of GIST which can be detrimental in acute cases as illustrated here. It is important to have GIST as one of the differentials when faced with a patient presenting with non-specific GI symptoms.

Trans-oral endoscopic endocrine surgery vestibular approach: Pioneering the technique in the Gulf Cooperation Council Countries - A case series.

BACKGROUND: We present our experience with the first five thyroidectomies and parathyroidectomy in Kuwait performed via the transoral endoscopic vestibular approach. METHODS: Retrospective data collection for all trans-oral endoscopic vestibular approach endocrine surgeries performed at a single institution in Kuwait between November 2019 and February 2021. Information on patient demographics, perioperative management and complications were collected and reviewed. OUTCOMES: All 5 cases were completed successfully; the intended specimen was extracted successfully via the trans-oral endoscopic vestibular approach and conversion to traditional trans-cervical approach (TCA) was not required. Operative time for the parathyroidectomy case was 225 min and the average operative time for the remaining 4 cases, thyroidectomies, was 151 min. Blood loss was minimal, and length of hospital stay was between 24 and 48 h. One patient had a transient mental nerve injury, and one patient experienced a postoperative seroma which required aspiration. One case required completion thyroidectomy as histopathology revealed papillary thyroid carcinoma. CONCLUSION: Transoral vestibular approach is a scar free and safe approach to thyroidectomies and parathyroidectomies. Careful patient selection and counselling with regards to risk versus benefit is required. It is an excellent alternative to the traditional transcervical approach and offers great cosmetic results.