Granulomatous mastitis: presentation, treatment and outcome in 43 patients.

BACKGROUND: Granulomatous mastitis is a rare benign breast condition commonly affecting women of child-bearing age. It is characterised histopathologically by the presence granuloma and microabscess formation. It is frequently mistaken for inflammatory breast carcinoma both clinically and mammographically. The aim of this study was to retrospectively review the clinical presentation, radiological investigation, histopathological features, treatment and outcome of granulomatous mastitis of women presenting to Ripas Hospital between October 1997 and June 2009. RESULTS: Forty-three patients with a mean age of 34 years presented with a diagnosis of granulomatous mastitis. All patients presented with a palpable breast lump; 24 (56%) patients also experienced pain in the lump and 3 (7%) patients also had associated nipple discharge on presentation. The role of radiological imaging is found to be limited in differentiating GM from other inflammatory and malignant conditions of the breast. Forty (93%) patients underwent a surgical procedure as the main treatment; in the form of excision or incision and drainage of the breast lesions. Mean follow-up was 15 (range 1-80) months with recurrence in 10 (23%) patients. CONCLUSION: Granulomatous mastitis presents clinically with a palpable breast lump. The diagnosis is often only made histopathologically after surgical excision or core biopsy. Complete surgical excision or incision and drainage of the lesion are the main treatment modalities. Treatment with corticosteroids and immunosuppression remains controversial and there is tendency for this condition to recur after treatment.

Development of the RIPASA score: a new appendicitis scoring system for the diagnosis of acute appendicitis.

INTRODUCTION: Acute appendicitis is one of the most common surgical emergencies. The Alvarado and modified Alvarado scores have been developed to aid diagnosis, but both scoring systems have poor sensitivity and specificity when applied in Middle Eastern and Asian populations. The aim of this study was to develop a new scoring system that is suitable for the local population. METHODS: Clinical data from 312 patients who had undergone an emergency appendicectomy was retrospectively collected and used to generate 15 parameters. The probability was calculated and a score of 0.5, 1.0 or 2.0 was allocated to each parameter. The receiver operating curve (ROC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the new scoring system were derived using the StatsDirect statistical software. RESULTS: The 15 parameters and the scores generated were age (less than 40 years is 1 point; greater than 40 years is 0.5 point), gender (male is 1 point; female is 0.5 point), right iliac fossa (RIF) pain (0.5 point), migration of pain to RIF (0.5 point), nausea and vomiting (1 point), anorexia (1 point), duration of symptoms (less than 48 hours is 1 point; more than 48 hours is 0.5 point), RIF tenderness (1 point), guarding (2 points), rebound tenderness (1 point), Rovsing's sign (2 points), fever (1 point), raised white cell count (1 point), negative urinalysis (1 point) and foreign national registration identity card (1 point). The optimal cut-off threshold score from the ROC was 7.5, with a sensitivity of 88 percent, a specificity of 67 percent, a PPV of 93 percent and an NPV of 53 percent. The negative appendicectomy rate decreased significantly from 16.3 percent to 6.9 percent, which was a 9.4 percent reduction (p is 0.0007). CONCLUSION: The new appendicitis scoring system looked promising when applied to our settings, and had a better sensitivity and specificity than the Alvarado score when applied to Asian populations. A significant reduction in the negative appendicectomy rate was also predicted. A prospective evaluation of this new appendicitis scoring system, referred to as the RIPASA score, is ongoing.

Lymphangioma of the epididymis.

We report herein a 39-year-old man with a left scrotal swelling. The clinical and ultrasonographic appearances were suggestive of epididymal cyst. Histopathology of the excised lesion was shown to be lymphangioma of the epididymis. The differential diagnoses of a swelling in the scrotum of a young man include both benign and malignant conditions. Lymphangioma of the epididymis is, however, a rare and unusual cause.

Laparoscopic adrenal-sparing surgery for primary hyperaldosteronism due to aldosterone-producing adenoma.

BACKGROUND: Laparoscopic adrenalectomy has been shown to be safe and effective in the treatment of patients with primary hyperaldosteronism due to aldosterone-producing adenoma. Most laparoscopic adrenalectomies for aldosterone-producing adenomas involve total removal of the adrenal gland, and there have been few reports of laparoscopic adrenal-sparing surgery or partial adrenalectomies. METHODS: A prospective review is performed on eight patients with primary hyperaldosteronism due to aldosterone-producing adenoma who underwent laparoscopic transperitoneal adrenal-sparing surgery in our institution over a 2-year period. RESULTS: There were 1 male and 7 females with a mean age of 43.1 years. The mean diameter of the adenoma was 2 cm; there were six right-sided lesions and two left-sided lesions. The adenoma was located in the anterior margin of the adrenal gland in seven cases and was removed by laparoscopic enucleation. One patient had a partial adrenalectomy using the vascular stapler for an adenoma that was located posteriorly in the adrenal gland. Hemostasis was excellent in all cases. All patients were able to tolerate liquid orally on the day of operation and were on diet on the second postoperative day. Postoperative analgesic requirement was minimal. The mean hospital stay was 3.8 days. At a mean follow-up of 25 months, seven patients were cured of their hypertension and one patient had her antihypertensive medications significantly reduced. CONCLUSION: Laparoscopic transperitoneal adrenal-sparing surgery is safe and effective in the treatment of patients with primary hyperaldosteronism due to aldosterone-producing adenoma.

Treatment and outcome of cystosarcoma phyllodes in Brunei: a 13-year experience.

Cystosarcoma phyllodes is a rare tumour of the breast whose clinical behaviour does not correlate well with histological findings. The optimal treatment of this tumour remains controversial. A retrospective study on the treatment and outcome of women diagnosed with cystosarcoma phyllodes between 1986 and 1998 in Brunei was undertaken. Twenty-seven women were diagnosed over the 13-year study period. Follow-up was complete in 26 cases. The mean age at diagnosis was 35 years. There were 19 (73%) histologically benign lesions, 3 (12%) borderline lesions and 4 (15%) malignant lesions. The mean follow-up period was 37 months. Four patients (16%) had recurrences after surgery (1 benign, 1 borderline and 2 malignant lesions). Mean time to recurrence was 9 months. Breast-conserving surgery with adequate resection margin is advocated in benign and borderline lesions. For malignant lesions, simple mastectomy without routine axillary dissection is recommended. More research is required to determine the role of adjuvant chemotherapy and radiotherapy in the management of malignant cystosarcoma phyllodes [corrected].

Laparoscopic drainage of postoperative complicated intra-abdominal abscesses.

Intra-abdominal abscess, which carries significant rates of death and complications, may complicate the postoperative course. Treatment options include percutaneous needle aspiration, placement of an external drain under ultrasonic guidance, or surgical drainage, depending on the size, site, and nature (simple or complicated) of the abscess. Laparoscopic drainage may be a treatment option. A retrospective review of patients who underwent laparoscopic drainage of postoperative complicated intra-abdominal abscesses at the authors' institution from January 1997 to July 1999 was performed. Seven patients had complicated intra-abdominal abscesses 7 to 17 (mean 11) days after their initial operation. All abscesses were successfully drained by laparoscopy. The mean operative time was 64 minutes. There were no intraoperative or postoperative complications. The postoperative analgesic requirement was minimal. The suction drain was removed on average 5 days after laparoscopy, and the mean hospital stay was 6 days. There was no recurrence of symptoms at a mean follow-up of 23 months. Laparoscopic drainage, in combination with systemic antibiotics, is a safe and effective treatment option in patients with postoperative complicated intra-abdominal abscesses.

Laparoscopic excision of congenital bladder diverticulum in a child.

Laparoscopy is being used more and more often in pediatric surgery for diagnostic and therapeutic indications. We report the successful laparoscopic excision of a congenital bladder diverticulum in a 6-year-old child. The minimally invasive approach allowed for easy identification and dissection of the diverticulum and surrounding vital structures with minimal postoperative pain and a good cosmetic result.

Tuberculosis of the bile duct: a rare cause of obstructive jaundice.

Tuberculosis of the bile duct is extremely rare. Patients with this condition usually present with a protracted illness and obstructive jaundice, which may be confused with hepatobiliary malignancies. A retrospective review of hospital records of patients who presented with tuberculosis of the bile duct between January 1986 and December 1996 was undertaken, and data were obtained concerning clinical presentation, investigations, treatment, and follow-up. Four patients (one man and three women) with a mean age of 44.8 years had tuberculosis of the bile duct. Diagnostic imaging techniques showed bile duct dilation in all four patients. Endoscopic retrograde cholangiopancreatography (ERCP) showed a stricture in the proximal common bile duct (CBD) in one patient, a stricture in the distal CBD in one patient, a stricture in the common hepatic duct (CHD) in one patient, and multiple strictures in the CHD and left intrahepatic duct in one patient. Bile cytology and fine-needle aspiration identified correctly the diagnosis in each patient. Two patients underwent laparotomy with the initial suspicion of cholangiocarcinoma; the correct diagnosis was made based on frozen sections taken intraoperatively. One patient was treated with endoscopic stenting and three patients underwent laparotomy for bile duct obstruction. All patients received antituberculous therapy. There were no deaths; all patients remained healthy at a mean follow-up of 36.5 months. It is important to obtain a tissue diagnosis in all patients with obstructive jaundice to avoid missing this rare but curable disease. The treatment of tuberculosis of the bile duct involves relief of the bile duct obstruction and antituberculous therapy.

Isolated hepatic tuberculosis: report of five cases and review of the literature.

Tuberculosis is one of the most common and well-described infectious diseases, with a worldwide distribution and a vast spectrum of clinical manifestations. Involvement of the liver alone by tuberculosis is, however, uncommon. It usually presents as a protracted illness frequently associated with jaundice and hepatomegaly. It can, therefore, mimic primary or metastatic liver malignancies. We report five cases of isolated hepatic tuberculosis, emphasizing the importance of obtaining a tissue diagnosis in all subjects with suspicious liver lesions to avoid missing the uncommon but curable hepatic tuberculosis.

Laparoscopic omental patch repair for perforated duodenal ulcer.

A retrospective review was carried out on 33 consecutive patients with omental patch repair for perforated duodenal ulcer; 13 had laparoscopic repair, and 20 had open repair. Laparoscopic repair was successful in 12 patients, with only one postoperative complication (8%). The morbidity rate for open repair was 15 per cent (3 of 20), and there was one postoperative death in the open group (5%). Overall, it did not take longer to perform the operation laparoscopically than the open method. Patients in the laparoscopic group required less postoperative analgesia (mean doses, 0.2 vs 0.9; P = 0.02). There was no difference in terms of hospital stay and resumption of diet after operation between the two groups. Laparoscopic omental patch repair offers a safe alternative to the open method in the treatment of perforated duodenal ulcer.

Colonoscopic evaluation of severe hematochezia in an Oriental population.

BACKGROUND AND STUDY AIMS: Hematochezia is a common clinical problem. When the bleeding is brisk and continuous it requires prompt hospital admission and careful diagnostic evaluation and management. Colonoscopy has become the first-line investigative modality in patients presenting with severe hematochezia in many centers, including ours. A retrospective review was carried out to evaluate the effectiveness of colonoscopy in determining the cause of severe hematochezia in our Oriental population. PATIENTS AND METHODS: One hundred and ninety patients with severe hematochezia underwent colonoscopy at the National University Hospital, Singapore, from 1 January 1988 to 31 December 1994. Their records were retrieved and the data analyzed for sex, age, presentation, concomitant medical conditions, prevalence of recent non-steroidal anti-inflammatory drugs ingestion, past history of hematochezia, investigations, subsequent interventions and outcome. RESULTS: Colonoscopy as the fist-line investigative modality identified the site and cause of hematochezia in 78% (148/190) of cases. The site of bleeding remained "obscure" even after additional investigations in 15% (29/190) of cases. The commonest cause of severe hematochezia in our Oriental population was diverticular disease (30%, 57/190) with right-sided diverticular bleeding constituting 44% (25/57) of these cases. Overall, bleeding stopped spontaneously in 81% (154/190) of cases. Surgery was performed in 16% (30/190) of cases. The mortality related to severe hematochezia in this series was 5% (9/190). CONCLUSIONS: The diagnostic efficiency of colonoscopy in defining the site and cause of severe hematochezia in the Oriental population is comparable to most Western series. The commonest cause of severe hematochezia in our population was diverticular disease.

Management of Mirizzi's syndrome in the laparoscopic era.

BACKGROUND: Mirizzi's syndrome is an uncommon cause of common hepatic duct obstruction resulting from gallstone impaction in the cystic duct or gallbladder neck. The role of laparoscopic surgery in the treatment of this condition is still not well defined. This article reports six cases of Mirizzi's syndrome and comments on the management of this condition using the laparoscopic approach. METHODS: A review of 878 consecutive cholecystectomies from July 1991 to July 1996 identified six cases of Mirizzi's syndrome (0.7%) that were approached laparoscopically. RESULTS: This study involved three men and three women with mean age of 64 (range, 57-70) years. All cases were approached by laparoscopy. One case was converted because of unclear anatomy in the Calot's triangle due to dense adhesions; open cholecystectomy, exploration of the common bile duct and T-tube insertion was performed. The other five cases were successfully managed laparoscopically. Subtotal cholecystectomy was performed in two cases, and in three patients with cholecystocholedochal fistula, the defect was closed over a T tube. There was no postoperative morbidity or mortality. A follow-up period of 8 to 17 (mean, 12) months revealed no complications. CONCLUSIONS: Laparoscopic management of Mirizzi's syndrome is feasible and safe but can be technically demanding. A policy of trial dissection by an experienced laparoscopic surgeon is recommended, and if anatomy remains unclear, it is prudent to convert.

A prospective review of laparoscopic cholecystectomy in Brunei.

Brunei has a small population and a unique medical setup: The number of laparoscopic cholecystectomies (LCs) performed in our institution represents the total number of cases performed in this country. A prospective analysis of all the LCs performed in Brunei is presented. All 220 LCs performed between February 1, 1992, and November 30, 1996, were prospectively recorded on a detailed protocol. Analyses were made with respect to preoperative patient demography, intraoperative complications, and postoperative morbidity and mortality. Symptomatic gallstone disease was found to be common among the ethnic Nepalese population. In this series, nine patients required conversion to open surgery (4%). Acute cholecystitis comprised 21% of cases, and the mean operating time was longer in these cases (144.1 min) than in elective cases (101.2 min; P = 0.002). The overall morbidity was 5% with one ductal injury (0.5%). The mortality rate in this series was 0.5%. Our results of LC are favorable and comparable with those of published series. We conclude that LC has been successfully introduced into our institution. This study also represents an unofficial audit of the state of development of LC in Brunei.

PIP: Laparoscopic cholecystectomy for the treatment of gallstone disease has the advantages of a shorter postoperative stay, more rapid overall recovery time, and better cosmesis compared to open cholecystectomy. To assess the state of development of laparoscopic cholecystectomy in Brunei, a prospective review of all 220 such procedures performed at the RIPAS Hospital in Bandar Seri Begawan in 1992-96 was conducted. These cases represent the total number of procedures performed in Brunei to date. The standard four-portal technique was used with an open Hasson trocar placed at the umbilicus. 81 patients (37%) were male and 139 (63%) were female; the mean age of patients was 46 years. Indications for the procedure included biliary colic (130 cases), acute cholecystitis (47 cases), and obstructive jaundice caused by gallstones (26). The mean operating time was 109 minutes. 9 patients (4%) required conversion to open surgery. The overall morbidity rate was 5%, with one ductal injury (0.5%). Gallbladder perforation with leakage of bile and/or gallstones occurred in 17% of cases. There was 1 death in this series (0.5% mortality), involving an 87-year-old woman with postoperative bronchopneumonia. 57% of patients did not require any form of analgesia in the postoperative period. The mean hospital stay was 3 days.

Laparoscopic splenectomy--a report of two cases.

Laparoscopic splenectomy for haematological diseases has recently attracted much attention and hailed as a viable alternative to traditional splenectomy using the laparotomy route. We report two cases of laparoscopic splenectomy for idiopathic thrombocytopenic purpura; the first of such procedures performed in Brunei. There was reduced post-operative pain, earlier return of gastrointestinal function and a reduced post-operative hospital stay.

Intermittent subacute intestinal obstruction due to a giant lipoma of the colon: a case report.

A case with intermittent subacute intestinal obstruction due to a giant lipoma of the colon is reported. A 57-year-old woman presented with intermittent pain in the central abdomen and clinical findings of subacute intestinal obstruction. She had had similar symptoms for the last five years. She was diagnosed to have a large polypoid lesion in the ascending colon on barium enema in 1990. However, no surgical treatment was offered to her at that time. At laparotomy, a 16 cm x 11 cm x 11 cm polypoid mass on a 3 cm long stalk in the ascending colon causing colo-colonic intussusception was seen. Subtotal colectomy was performed. Histology showed submucosal colonic lipoma.

Laparoscopic-assisted large bowel resection.

Laparoscopic colon resection is a viable alternative to open colectomy. For non-malignant lesions, laparoscopic resection of the affected large bowel is attractive. For malignant lesions, where resection for cure is highly dependent on lymph node clearance, laparoscopic resection has met with criticisms regarding the adequacy of nodal clearance that can be achieved laparoscopically. Several published studies have shown that the operation though technically demanding, does not compromise the extent of resection. We report a series of 43 cases of laparoscopic colon resection done sequentially and successfully from January 1992 to June 1995. The operative time averaged 180 minutes (range 120 to 300 minutes). Five patients developed postoperative complications, which were mainly pulmonary and wound infections. There were no anastomotic leaks or perioperative deaths. The mean hospital stay was 5.3 days (range 4 to 9 days). By the third postoperative day, all patients were feeding and ambulatory. Long-term complications included one small bowel obstruction and one port site recurrence. In our selected group of patients, laparoscopic colon resection has not shown any adverse outcome. Prospective randomised studies are underway in various centres and their preliminary results are favourable.