Avoiding Many Operative Scars in Patients with Recurrent Fibroadenomas of the Breast

Posted on April 9, 2012 by rojoson

Avoiding Many Operative Scars in Patients with Recurrent Fibroadenomas of the Breast

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

April 9, 2012

Fibroadenomas of the breast are quite common among the Filipino females.  They are non-cancerous breast mass.

Currently, the most practical way to resolve the problem of an annoying fibroadenoma mass is open excision or operative removal utilizing an incision on the breast skin.

A common challenge among breast surgeons is how to avoid multiple scars on the breast on patients with recurrent fibroadenomas.

Recently, March 2012, I have this patient, RV, a 37-year-old female, with two (2) recurrent fibroadenomas on her left breast, whom I have to do an open excision.

I had operated on her before for fibroadenomas on her two breasts, about 2 to 3 times already.  In each operation, I tried to place the incision in an area that will not produce a conspicuous scar, such as along the border of the areola or utilizing old incisional scars.

In this latest operation, I utilized her previous scars on the breast even if the 2 masses were a distance away.  I did not create new incisions.  Before the operation, I had an informed consent to make an incision over the masses just in case it will be difficult to remove them through the previous scars.

During the operation, however, with the patient under general anesthesia, I was able to remove the 2 masses using her previous  incisional scars without creating new incisions.  If I did the latter, I will be adding more scars to her breasts.  After the operation, the patient was very happy and thank me for what I did.

Below are the pictures of my operation with some annotations.

Above picture showing the locations and sizes of the fibroadenomas and the 3 scars from previous excisions.

If I were to put the incisions over the two new masses, there will be resultant 5 scars after the operation.

CALL IT COMPASSION, I DECIDED NOT TO PUT INCISIONS THAT WOULD RESULT IN MORE SCARS ON THE PATIENT’S BREAST.  ALTHOUGH MORE DIFFICULT TO EXCISE THE BREAST MASSES, I USED THE EXISTING SCARS FOR MY INCISIONS.

Above picture shows the locations of the masses, the incisions, and the masses after removal.

How I did it? Tunneling, pushing the masses towards the incision, patience and perseverance for the sake of the patient’s well-being.

The resultant wounds after the operation – NO additional breast scars for the patient.

Strategies in preventing medicolegal suits from patients and relatives

Best strategies in preventing medicolegal suits from patients and relatives:

• Informed consent
• Rapport from patients and relatives
• Due diligence from physicians

Pancreaticoduodenectomy – A Brief Review of Past Experiences and Sharing of Recent Experience and Learning

Pancreaticoduodenectomy – A Brief Review of Past Experiences and Sharing of Recent Experience and Learning

Reynaldo O. Joson, MD, MHA, MHPEd, MSc Surg

March 11, 2012

Pancreaticoduodenectomy is an operation that removes the pancreas and its intimately adjacent duodenum or vice versa, the duodenum and its intimately adjacent pancreas.

The indications for such an operation are resection of malignant tumor in the area (pancreaticoduodenal area), extensive trauma to the area, and extensive necrosis to the duodenum as a result of swallowing of corrosive substances such as muriatic acid.

I reviewed my records on pancreaticoduodenectomy from my surgical residency years up to the present.

During my residency years in the Philippine General Hospital from 1976 to 1981, I have done only 3 pancreaticoduodenectomy, one for malignant tumor and 2 for extensive pancreaticoduodenal injuries.

In 1989, I wrote a paper, “Factors affecting outcome in pancreatic injuries,” which was published in the Philippine Journal of Surgical Specialties.  [Factors affecting outcome in pancreatic injuries.  Joson RO.  Philipp J Surg Spec 1989; 44(1); 24-29.]

After finishing my residency from the Philipppine General Hospital, from 1981 up to the present, I have done only a few cases of pancreaticoduodenectomy.  I cannot recall the exact number.  My estimate is about 5 cases and mainly for periampullary carcinoma.

The few cases that I have may be due to few referrals and few cases of periampullary carcinomas in the community.  Ampullary carcinomas are usually amenable to pancreaticodudenectomy at the time of diagnosis as compared to malignancies in the head of the pancreas.  The latter usually are not amenable to pancreaticoduodenectomy at the time of diagnosis and a bypass is just done.  Between ampullary malignancies and pancreatic head malignancies, the former is not very common.

A pancreaticoduodenectomy for ampullary carcinoma entails cutting at the distal part of the stomach or first portion of the duodenum, common hepatic duct, neck of the pancreas, and proximal part of the jejunum.  There are usually three reconstructions after the pancreaticoduodenectomy, namely, pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy.

Below are some pictures on pancreaticoduodenectomy that I recently did on a 61-year-old female with ampullary carcinoma.

The specimen showing the part of the stomach at the right upper portion of the picture, the proximal end of the jejunum at the right lower portion, the gallbladder and the common bile duct at the left upper portion and the duodenum with head and neck of the pancreas at the left lower portion.

The specimen cut open showing a stent protruding through the ampulla of Vater and with a bulge in the area of the ampulla signifying the presence of a mass about 1.5 cm.  Note also the erythematous lesion at the opening of the ampulla.

A close-up view of the lesion and bulge at the ampulla of Vater.

Intraoperative picture of the field after the pancreaticoduodenectomy – the cut hepatic duct with silk sutures at the left upper portion; the clamped jejunal end at the left lower portion; the clamped gastric end at the right lower portion; the cut end of the pancreas pointed to by a clamp in the right upper portion; and the portal vein-superior mesenteric vein just to the left of the transected pancreas.

Reconstructions done (illustration courtesy of http://www.findthatfile.com/search-7720422-hPDF/download-documents-1550092707.pdf.htm)

In the pancreaticojejunostomy, a duct to mucosa anastomosis was done.  See illustrations below courtesy of http://www.findthatfile.com/search-7720422-hPDF/download-documents-1550092707.pdf.htm.

Another method of pancreaticoduodenostomy (invagination into the jejunum) which I have done before is illustrated below.

Personal Insights:

A liberal mobilization of the duodenum facilitates the operation.

The operative time can range from 4 to 8 hours.

PBLI: What is the recommended margin of resection during total mastectomy (part of modified radical mastectomy) for breast cancers?

PBLI: What is the recommended margin of resection during total mastectomy (part of modified radical mastectomy) for breast cancers?

Corollary PBLI: What is the recommended margin of wide excision for breast cancers?

Welcome answers and discussion.

Below is the recommended margin of 5 – 7.5 cm in Zollinger’s Atlas of Surgical Operations, 2011 edition.

I don’t follow this.

I usually allow about 2 cm margin when planning the elliptical skin incision. I am reviewing this practice of mine.

Dr. Rey

PBLI – Fibroadenoma in Male Breasts – Very Rare and Very Unlikely

Fibroadenoma in Male Breasts – Very Rare and Very Unlikely

Posted on January 29, 2012 by rojoson

Fibroadenoma in Male Breasts – Very Rare and Very Unlikely

Last January 17, 2012, a surgical resident made a postoperative diagnosis of fibroadenoma after operating on a male patient with a breast concern.  I commented that in my entire 30 years of practice, I have not made a diagnosis of fibroadenoma in a male patient nor have I received a histopathologic report of fibroadenoma in  a male patient.  I asked somebody to look up this problem-based learning issue for verification.   A resident reported and supported my comment.

Fibroadenomas usually develop from lobules of the breast.  Since male breasts usually don’t have lobules, we don’t expect to see fibroadenomas in males.   If there are, they are extremely extremely rare.  So, my advice is to be very very careful to make a diagnosis of a fibroadenoma in a male.  Chances are, you will be questioned and you are wrong.

Leonard M. Glassman said something to this effect:

Fibroepithelial lesions are extremely rare because they start in the lobules.
So do not diagnose a fibroadenoma in a man, even if it looks like a fibroadenoma.
When you get a biopsy result that says fibroadenoma, get another pathologist.

http://www.radiologyassistant.nl/en/49a3cce262026

References:

1. Robbins and Cotran. Robbins Pathologic Basis of Disease. 8^th Ed. 2010
2. Rosai and Ackerman. Surgical Pathology. 9^th Ed. 2004
3. Glassman, Leonard. Male Breast. The Radiology Assistant. 2009

Body Surface Area Nomogram

Based on the formula of Du Bois.

BSA_nomogram_adult_pedia_rj_12jan23

I will be using this to nomogram to facilitate my calculation of BSA in meter square for my patients undergoing chemotherapy.

I will keep a hard copy in my clinic and a soft copy in my computers in my clinic.

My personal BSA as of today, January 23, 2012, based on 75 kg and 167 cm, is 1.8.

Problem-based Learning Issues in Surgery and Self-directed Learning

Problem-based Learning Issues in Surgery

Every time I have an operation, whenever I discuss my patient with residents and interns who are assisting me and whenever I do introspection on the patient on hand, I always discover I have gaps in knowledge.  These gaps are what I call problem-based learning issues (PBLI).

What do I do with the PBLI?

I try to look for the answers usually through the Internet, at times, through asking people whom I think have the answers and also reading books that are available.  Whatever answers I get, I process and transform them into knowledge which I store in my brain for future use, particularly, for purpose of refining my management of current as well as subsequent patients presenting with the same or almost similar kind of medical or surgical problems.

This is how I continually learn medicine and surgery.  This is how I continually improve my competency in managing patients.  This is how I continually improve myself as a physician and a surgeon.

This type of learning that starts with self-identification of gaps of knowledge (PBLI) and then proceeding to actively looking for the answers for purposes of self-improvement is what is called self-directed learning.  This is the kind of learning that all medical educators are advocating as the best way for physicians to learn medicine and surgery initially in schools and eventually, after leaving schools.

I also am advocating this as seen in my personal practice described above and in the problem-based learning medical curriculum that I formulated in 1994 that is being used by Ateneo de Zamboanga Medical School (formerly, Zambaonga Medical School Foundation) and other schools in Luzon and in the Visayas.   I have also been advocating problem-based learning in the Department of Surgery of Ospital ng Maynila Medical Center since 2001 and in my preceptorial sessions in the University of the Philippine College of Medicine, Department of Surgery, and Manila Doctors Hospital.

Skin Tag or Acrochordon

ROJOSON’s  Problem-based Learning  on Skin Tags

Trigger: May 3, 2011, I operated a patient with a pedunculated mass on the back under local anesthesia and on an outpatient basis.

My preoperative and intraoperative diagnosis was squamous papilloma, back.

During and after my operation, I did an introspection and problem-based learning discussion session with Drs. Athena Belita (intern) and Crisel Puzon (resident), who assisted me.

Issue1: Diagnosis

What is the correct term for the diagnosis?  Is it really “squamous papilloma” as I have been using it for the past 30 years?  A practice that I traced back to being influenced by the pathologists’ report after my every excision of such kind of a pedunculated mass.  I know there is another term being used  I just cannot remember it at that time.

For our problem-based learning issues, we decided on the following:

• Study of the terms being used.
• Check ICD-10 for the code and term to use for PhilHealth purpose.
• Recommend term/s to use.

I searched the Internet on May 3, 2011.

Findings:

Terms being used: skin tag, acrochordon, fibroepithelial polyp, and cutaneous papilloma, soft fibroma.

More commonly used terms: skin tag (lay) and acrochordon and fibroepithelial polyp (medical).

I discovered that “squamous papilloma” is defined as a wart-like or cauliflower-like growth caused by viral infection of the skin.

Cutaneous papilloma is more akin to skin tag and acrochordon and thus, can be used.  However, to avoid confusion and interchanging of the two phrases, with squamous papilloma having the implication of a viral cause, from now on, I will stop using “squamous papilloma” for skin tag.

ICD-10 does not contain the terms mentioned above: skin tag, acrochordon, fibroepithelial polyp, and cutaneous papilloma, soft fibroma.

Recommendations:

1. Do not use “squamous papilloma” for skin tag as it is most likely erroneous and has different implication.

2. Use skin tag, acrochordon, fibroepithelial polyp, or cutaneous papilloma instead.  Note: investigate on HMOs’ concerns – what term to use to facilitate coverage, most likely, use acrochordon and fibroepithelial polyp.  Skin tag may NOT be covered by HMOs as they are considered cosmetic concerns.

3. Suggest using the following code under ICD-10:

L91.8 Other hypertrophic disorders of skin 

(Note: I guess one can place the commonly used terms after the code.  Example: L91.8 (Skin tag or acrochordon or  cutaneous papilloma)

NOTE: On May 10, 2011, when the patient followed up with me, I saw the histopath report: “Squamous papilloma.”  This confirms what I said in my introduction to Issue 1.

“What is the correct term for the diagnosis?  Is it really “squamous papilloma” as I have been using it for the past 30 years?  A practice that I traced back to being influenced by the pathologists’ report after my every excision of such kind of a pedunculated mass.”

Despite this, I maintain my recommendations NOT to use “squamous papilloma” for a skin tag.

Issue 2: How to measure the fibroepithelial polyp

Consensus:

a. Diameter of the base from which the peduncle arises

b. Length of the stalk

c. Diameter of the mass or tumor on the stalk

Issue 3: Cause/s

Friction such as skin rubbing against skin as skin tags are commonly located near areas of the body with creases, such as armpits and groins.

Also, skin tags are hypothesized to arise in areas where skin frequently rubs against clothing.

Note: skin tags become more common as one grows older and older

Issue 4: Treatment

Indications of treatment:

• Cosmetic concern on the part of the patient
• Pain and irritation on accidentally hitting or pulling on the skin tag
• Continuous annoyance with its presence (on the part of the patient)

Otherwise, it can be left alone (no active treatment of eradication) but with watchful waiting by the patient / relative / physician.

Options of treatment (if it has to be treated):

Goal: to resolve the skin tag concern by eradicating it.

Options	Benefit	Risk	Cost	Availability
Topical application of medical products, oils, extracts, etc.H-Skin Tags,Dermisil (plant extracts) [US products]	Takes time to eradicate2 to 6 weekshttp://www.amoils.com/skin-tags-removal.html	PainInfection	Cost of medicinal products	Not certain of availability in the Philippines
Tying with a thread (or dental floss)	Takes time to eradicateReported slough off time: 48 hours after tyingResidual stalk at the base upon sloughing off (not flushed to the skin level)Depending on tightness of tying, may not slough off Personal experience, took one week for skin tag to spontaneously slough off after tying	Pain on tyingDiscomfort while waiting for the skin tag to slough off and waiting for the base to healInfectionBleeding	No expense on physician, health care facilityExpenses –  antiseptics,  dressing, and analgesics	Tying materials readily available
Cutting using scissor or blade without anesthesia  then pressure to control bleeding in  wound at base	Instant eradicationTakes time to control bleeding at base	Pain on cuttingBleedingInfection	Expense on physician; health care facilityOther expenses –  antiseptics,  dressing, and analgesics	Cutting instruments readily available
Cutting with anesthesia then cauterizing the resulting wound at the base	Instant eradicationInstant control of bleeding in wound at the base	Pain of anesthestic infiltrationInfection	Expense on physician; use of cautery equipments (P500 to 1500); health care facilityOther expenses –  antiseptics,  dressing, and analgesics	Issue of availability of cautery equipment
Cutting with anesthesia then suturing the resulting wound at the base	Instant eradicationInstant control of bleeding in wound at the base	Pain of anesthestic infiltrationInfection	Expense on physician; sutures (P400); health care facilityOther expenses –  antiseptics,  dressing, and analgesics	Issue of availability of suturing equipment and sutures

Pictures of skin tags

Some References for Further Readings:

http://www.nlm.nih.gov/medlineplus/ency/article/000848.htm

http://www.medicinenet.com/skin_tag/article.htm

ROJOSON’s 2011 Legacy Plan

ROJOSON’s 2011 Legacy Plan

ROJ Legacies	Husband / Parent	Hospital / Department Administration	Medical / Surgical / Health Education	Well-being and Medical Management
Family	√ (Husband / Parent)
Philippines			√ (Health)
Patients			√ (Health)	√ (Well-being and Medical Management)
Students		√ (Hospital Administration)	√ (Medical / Surgical Education)
Manila Doctors Hospital / Department of Surgery		√	√ (Surgical Education)
Ospital ng Maynila Medical Center / Department of Surgery		√	√ (Surgical Education)
Philippine General Hospital Department of Surgery and GSI Division		√	√ (Surgical Education)
University of the Philippines College of Medicine			√ (Medical Education)

 

Concepts of Problem-based Learning in Medicine (in Surgery)

This was derived from a module which I wrote in 1997 with the title: Problem-based Learning in Medicine, An Off-campus Study.

I will be using these concepts when I write my blog on “Problem-based Learning in Surgery.”

ROJoson – May 18, 2011

+++++++++++++++++++++++++++++++++++++++++++

What is Problem-based Learning (PBL) in Medicine (in Surgery)?

PBL is the learning that occurs in the process of solving a problem.  Experience has shown that this is mainly how human beings learn to live life and it is undeniably the best way of learning especially in terms of retention and recall of knowledge and skills.

The   founders of PBL in medicine recalled their sad experiences with the conventional memory-based medical curriculum – hard to recall facts “learned” in the first 2 years and difficulty in integrating the basic and clinical sciences.   They theorized that retention and recall of medical knowledge and skills would be enhanced when learned in a context which closely approximates real life, i.e. clinical problems.

Thus, PBL in medicine has been proposed and it is essentially learning the science and art of medicine in the clinical or functional context.

In the practice of medicine, the following events actually or should take place:

1. A physician meets a patient without prior knowledge of what the patient’s problem is.

2. During the encounter, the physician establishes rapport, diagnoses, treats, and gives advices with the goal of resolution of the health problem of the patient.

3. In the process of understanding and resolving the patient’s problem, the physician invariably encounters some insecurities, questions, and gaps in competencies.

4. The physician fills in the gaps in competencies through various means, such as self-study and learning from other people like consultations, referrals, and enrolling in a formal course.

5. The new competencies acquired are used by the physician on the patient on hand and on future patients.

If PBL in medicine is learning the science and art of medicine in the functional context, then the educational activities should consist of the following:

1. The student is presented with a health problem which can be simulated or actual, without the student having prior study on the problem.  This means there is no prior teacher’s lecture nor prior assignment to study on the problem.

2. The student tries to understand and to solve the problem.

3. In the process of trying to understand and to solve the problem, the student will invariably encounter questions, uncertainties, and gaps in competencies, which constitute the so-called “learning issues”.

4. The student then decides how to go about settling the “learning issues”.

5. The student implements his plan of study.

6. The student applies what he learned to the problem on hand as well as to future problems or patients.