Problem-based Learning in Surgery – For My Continuing Self-education and for Surgical Trainees – Part of Education for Health Development in the Philippines
Analgesia is a pain-free state without loss of consciousness, whereas anesthesia is a state achieved when there is a loss of touch, pain, and temperature sensations with or without loss of consciousness.
In the process of doing RRR (Re-study, Refine, Reaffirm) of my knowledge and advice, I ask this question:
There is a clinically diagnosed soft tissue cyst – example, thyroid colloid cyst; breast macrocyst; ganglion cyst; mucus cyst or mucocoele. After I aspirated the fluid, do I have to subject the specimen for a biopsy? Biopsy means a microscopic examination. The specimen can be prepared as a smear on a glass slide or the fluid submitted for a cell block (the specimen is processed to for a paraffin block). Whichever form, the microscopic examination is called a cytopathologic examination meaning cells and not tissues are examined. (Microscopic examination of tissue specimen constitute a histopathology.)
My answer is: it depends but most of the time, NO need. I usually get a informed consent for the “needle evaluation and aspiration with or without biopsy.”
This is how I usually explain to patients before the procedure.
I will tell them my pre-procedure diagnosis accompanied by a degree of certainty or uncertainty or my diagnosis. Of course, there is no such thing as 100% certainty. If my diagnosis is a cyst (example, thyroid colloid cyst; breast macrocyst; ganglion cyst; or mucus cyst) and my degree of certainty is more than 90% as high as 99% (primary based on the physical examination finding of a fluctuant or depressible mass), I will recommend to the patients “needle evaluation and aspiration with or without biopsy.”
I will explain that I will use a hypodermic needle to evaluate the mass initially, then aspirate and depending on my findings in the evaluation, I will decide whether to add or proceed to biopsy.
I will explain to the patients since I (or anybody for that matter) will never or cannot be 100% sure of a pre-procedural finding of a cystic mass and its associated diagnosis and with small chance it may turn out to be a solid or complex mass with other diagnosis, I may have to do a biopsy if indicated. “If indicated” means if I think there is a need for biopsy because of some unexpected findings on needle evaluation and aspiration. Example, if the mass turns out to be a soft solid or complex mass (meaning there is combination of cystic and solid elements) instead of completely cystic mass, my pre-procedural diagnosis will change. I usually will aspirate the solid elements and get sample of cells for biopsy in the same setting.
In the evaluation of the mass with the needle, pricking or poking the mass with the needle and with aspiration, I will be able to get the following information and come out with a gross diagnosis that will either validate my pre-procedural diagnosis or change it.
If the mass is really totally cystic, solid or complex (with cystic and solid components)
If the mass is solid, the feel of the mass whether hard or not hard; whether there is grittiness that may suggest cancer; whether it is rubbery that may suggest a benign tumor; etc.
If the mass is solid, the cellular aspirates placed on a glass slide can be examined with the naked eye (with experience, a clinician can discern gel, normal cells, suspicious-looking cells; etc.)
So, if on evaluation of the mass with the needle, I am able to aspirate fluid and the mass completely disappears, then I affirm my pre-procedural diagnosis that it is a benign cyst (example, thyroid colloid cyst; breast macrocyst; ganglion cyst; or mucus cyst). In this situation, my degree of certainty of a benign cyst is now at least 99% (which may also be 99.9%). With this, I do not have to submit a specimen for biopsy anymore.
As I said earlier (above), if on evaluation of the mass with the needle, the mass turns out to be a soft solid or complex mass (meaning there is combination of cystic and solid elements) instead of completely cystic mass, my pre-procedural diagnosis will change. I usually will aspirate the solid elements and get sample of cells for biopsy in the same procedural setting.
To repeat my answer to the question whether I need to do biopsy after a needle aspiration of cystic mass: it depends but most of the time, NO need. I usually get a informed consent for the “needle evaluation and aspiration with or without biopsy.”
Reinforcing illustrations:
If my clinical diagnosis before the needle procedure is a thyroid colloid cyst and I aspirated several cc of dark-brown or light brown colloid fluid followed by a complete disappearance of the mass (on palpation), my post needle procedure diagnosis is thyroid colloid cyst with 99% degree of certainty. I need not submit the fluid for a cytopathologic biopsy.
If my clinical diagnosis before the needle procedure is a breast macrocyst and I aspirated several cc of yellowish, greenish, grayish (not red – to suggest blood) fluid followed by a complete disappearance of the mass (on palpation), my post needle procedure diagnosis is breast macrocyst with 99% degree of certainty. I need not submit the fluid for a cytopathologic biopsy.
If my clinical diagnosis before the needle procedure is a wrist ganglion cyst and I aspirated several cc of colorless or transparent gel fluid followed by a complete or almost complete disappearance of the mass (on palpation), my post needle procedure diagnosis is wrist ganglion cyst with 99% degree of certainty. I need not submit the gel fluid for a cytopathologic biopsy.
I am preparing for a PEP Talk [Patient Empowerment Program – Talk] on the topic: Abdominal Hernia, tentatively to be done on June 4, 2022.
This page will contain my notes on ABDOMINAL HERNIAS as part of my problem-based learning process.
The PBL or PBLI will be on the following:
What are abdominal hernias?
What are the different types of abdominal hernias?
What are the causes of abdominal hernias?
Are there preventive measures against abdominal hernias?
How common are the abdominal hernias?
Clinical diagnosis of abdominal hernias
Paraclinical diagnostic procedures for abdominal hernias
Basic treatment modality for abdominal hernias
Management of inguinal hernias
What are abdominal hernias?
Abdominal hernias consist of a defect, a hole or weakness in the abdominal wall or a peritoneal or mesenteric aperture or opening inside the abdominal cavity that allows abdominal tissues or organs like the small intestines to bulge through or be trapped inside the aperture.
What are the different types of abdominal hernias?
There are two general ways of classifying types of abdominal hernias based on location.
External and internal abdominal hernias
Hernias indicated by specific location
There are also two general ways of classifying types of abdominal hernias based on cause.
Congenital and acquired hernias
Incisional and non-incisional hernias
External and internal abdominal hernias
External abdominal hernias are those in which abdominal organs or tissues leave their normal anatomic site and protrude towards the skin of abdomen because of a congenital or acquired defect, hole or weakness in the abdominal wall.
Internal abdominal hernias are those in which abdominal organs or tissues protrude through a peritoneal or mesenteric opening inside the abdominal cavity or through a defect in the inner wall of the abdominal cavity such as in the diaphragm and pelvic wall.
Hernias indicated by specific location
Inguinal hernias
Femoral hernias
Umbilical hernias
Epigastric hernias
Spigelian hernias
Incisional hernias
Diaphragmatic hernias
Hiatal hernias
Obturator hernias
Mesenteric hernias
Adhesion-associated hernias
Congenital and acquired hernias
Congenital hernias are those hernias present at birth. The defect, hole, or defect causing the hernia is present at birth.
Acquired hernias are those hernias developing after birth and whose weakness in the wall or presence other defects causing the hernias are due to causative factors occurring after birth.
Incisional and non-incisional hernias
An incisional hernia is a protrusion of tissue that forms at the site of a healing or healed surgical scar. It is due to a weakened abdominal wall associated with the surgical incision. An incisional hernia implies that a prior operation was done. In non-incisional hernias, there is no history of operation done in the areas of the hernias.
What are the causes of abdominal hernias?
There is a defect, a hole or weakness that allows internal organs or tissues to protrude or be inserted into causing a hernia.
The defect, the hole or weakness can be present at birth (congenital) or developing after birth (acquired).
Among the acquired hernias, prior operation producing weakness of the abdominal wall and adhesion-associated hernia is a cause. Other causes include aging, repeated straining, weight lifting and some rare medical diseases that cause weakness of the abdominal wall due to abnormal systemic collagen synthesis (such as Marfans Syndrome and Ehlers-Danlos).
Are there preventive measures against abdominal hernias?
For the congenital hernias, there are currently NO preventive measures.
For the acquired hernias, except for age and medical diseases that cause abdominal weakness, there are preventive measures. Proper operative technique of operative wound closure can prevent incisional hernias. Avoiding repeated straining and strenuous weight lifting can also prevent hernias to a certain degree.
How common are the abdominal hernias?
Some are common; some are rare.
Inguinal hernias are most common among the non-incisional hernias.
Clinical diagnosis of abdominal hernias
For external abdominal hernias, the first cue is an unusual bulge on the abdominal wall. The second cue is that the bulge becomes more prominent on increased intra-abdominal pressure like standing up; straining; and coughing and becomes less prominent to the point of reducible when the intra-abdominal pressure has decreased. The third cue is that the bulge can be reduced back into the abdominal cavity.
For internal abdominal hernias, these will be not evident on inspection and palpation of the abdomen. They are often diagnosed through an imaging procedure such ultrasound, CT-can, and MRI or during an exploratory laparotomy (opening of the abdomen) done because of intestinal obstruction (the internal abdominal hernias are subsequently discovered).
Paraclinical diagnostic procedures for abdominal hernias
Common paraclinical diagnostic procedures are the imaging procedures such as ultrasound, CT scan and MRI.
Basic treatment modality for abdominal hernias
The treatment is basically an operation to repair the hole, defect or weakness so that a hernia will not occur.
When there is an associated complication of incarceration and strangulation of small intestines, additional surgical procedures include reduction of the hernia and resection of the strangulated small intestines.
Management of inguinal hernias
Inguinal hernias are hernias at the groin.
These are the commonest types of abdominal hernias.
They are more common in the males than in females.
There are 2 types: indirect and direct hernias. There can be a combination of the two.
The inguinal hernias are commonly congenital, particularly the indirect ones. The direct hernias are usually acquired, in older people because of weakness due to age.
The inguinal hernias are recognized through a bulge in the groin area and the bulge is reducible. In those with complications such as incarceration and strangulation, the bulge may not be reducible and there will be skin discoloration (dark blue and even black) if there is already strangulation of the incarcerated small intestines.
Usually, inguinal hernias are diagnosed clinically without need for paraclinical diagnostic procedures.
Treatment is surgical with repair of the defect, hole or weakness preventing an occurrence of a hernia.
Reduction is done when there is incarceration.
Resection of strangulated small intestines is done when there is already strangulation.
Myth:
Can an inguinal hernia be cured by a supporter? No. A hernia truss or belt is a supportive undergarment for men designed to keep the protruding tissue in place and relieve discomfort. A hernia truss can help a patient with inguinal hernia feel more comfortable temporarily, but it doesn’t treat the hernia.
Can a groin hernia heal itself? Will it disappear spontaneously?
No. A groin hernia or any abdominal hernia cannot heal on on its own. If left untreated, the defect or hole of the hernia usually gets bigger with time. The presence of the defect or hole in a hernia is a constant risk for incarceration and strangulation of small intestines. A strangulated herniated intestine is one in which the blood supply to the intestines is cut-off as it is strangulated by the hernia.
Surgery is the only way to fix an inguinal hernia. The surgeon will push the bulging tissue back inside; close the hole or defect; and strengthen the abdominal wall with stitches and perhaps mesh.
I created this website, Problem-based Learning in Surgery, to contain all my notes on problem-based learning issues in surgery. Note: I have another website, ROJoson’s Notes on PBL in Medicine and Surgery, which was primarily intended to put my writings and notes on Problem-based Learning in Medicine and Surgery, the learning process, not the learning issues. However, over the years, I have placed problem-based learning issues on non-surgical domains in this website which I was hesitant to place in the website on Problem-based Learning in Surgery.
Continuing to post on these 2 websites on Problem-based Learning is a humble admittance that I don’t know everything about medicine and surgery but I will continue to learn the “issues” – medicine is a from cradle to grave learning.
ROJ-PBLI-Surg = ROJoson Problem-based Learning Issue in Surgery
Backstory: During my private practice from 1982 to present, I have always felt the inadequacy or incompleteness of the recommended evaluation of hemorrhoids in terms of severity. The standard evaluation has been using the grading or degree of hemorrhoids just in terms of prolapse of the hemorrhoids. Grade 1 – no prolapse; Grade 2 – prolapsing but spontaneously reducible; Grade 3 – prolapsing but can be reduced manually; and Grade 4 – prolapsed but cannot be reduced manually anymore. After evaluation of the hemorrhoids, I like to make a diagnosis that will include severity of the hemorrhoids so as to facilitate my advice on management. I use “mild, moderate and severe” instead of Grade 1, 2, 3 or 4.
If I tell the patients their hemorrhoids are mild, my management advice would be conservative like adjusting diet and lifestyle to prevent straining, laxatives, etc. No recommendation for surgery.
If I tell the patients their hemorrhoids are severe, my management advice would be surgery.
If I tell the patients their hemorrhoids are moderate, I give them the options of conservative and surgical management.
In determining the severity, aside from the prolapsing tendency of the hemorrhoids, I also look at the number and size of the hemorrhoids in the anal circumference. I would definitely conclude severe hemorrhoids when there is a permanent prolapse; circumferential distribution of hemorrhoids and huge size, say more than 4 cm.
These assessment criteria have been my own. I have been looking in the Internet for something that will go beyond the grading of hemorrhoids in terms or prolapse and would include a severity criteria or indications for operation.
Most recently, first week of May, 2022, I found 2 articles while I was preparing for my PEP Talk (Patient Empowerment Program Talk) on Hemorrhoids.
Happy to see this – it includes the number of columns and circumferential degree as well as bleeding.
Executive Summary – The Association of Colon & Rectal Surgeons of India (ACRSI) Practice Guidelines for the Management of Haemorrhoids—2016 ——-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346092/
Happy to see this classification that includes number of piles and size (in terms of circumferential distribution)
The above papers were published in 2016 and 2020 respectively. Starting 1982, I was thinking about this additional way of classifying hemorrhoids. I finally saw these additional criteria that I have been using 30 to 40 years after.
How do I make use of these 2 articles to refine my protocol? Do I still maintain the classification of severity of mild, moderate, and severe? How do I translate these severity degrees into treatment recommendations? Or do I concentrate on the indications for operation?
BLEEDING
Bleeding – patient is usually alarmed with bleeding hemorrhoids. Yes, hemorrhoids can bleed. However, they usually stop spontaneously even without hematinics.
My recommendation: For all hemorrhoids, prolapsing or not, big or small, if there is very severe bleeding, bleeding in the forms of jets and splashes, OPERATE right away.
Other situations, watch and wait. May give hematinics when there is persistent severe bleeding short of very severe bleeding or there is recurring episodes. For episodic and mild bleeding, no need for hematinics, just watch and wait.
NO BLEEDING; PERMANENTLY PROLAPSED INTERNAL HEMORRHOIDS; MORE THAN 50% OF ANAL CIRCUMFERENCE
My recommendation: OPERATION.
NO BLEEDING; PERMANENTLY PROLAPSED INTERNAL HEMORRHOIDS; LESS THAN 50% OF ANAL CIRCUMFERENCEORWITH 2 HEMORRHOIDS OR LESS
Options: Operation or no operation yet (try non-operative treatment)
Depends on tolerance threshold of patients to discomfort arising from the prolapsed internal hemorrhoids.
NO BLEEDING; REDUCIBLE PROLAPSED INTERNAL HEMORRHOIDS EITHER SPONTANEOULY OR BY MANUAL PUSH; MORE THAN 50% OF ANAL CIRCUMFERENCEORWITH 3 HEMORRHOIDS OR MORE
Options: Operation or no operation yet (try non-operative treatment)
Depends on tolerance threshold of patients to discomfort arising from the prolapsed internal hemorrhoids.
NO BLEEDING; REDUCIBLE PROLAPSED INTERNAL HEMORRHOIDS EITHER SPONTANEOULY OR BY MANUAL PUSH; LESS THAN 50% OF ANAL CIRCUMFERENCEWITH 2 HEMORRHOIDS OR LESS
Options: Operation or no operation yet (try non-operative treatment)
Depends on tolerance threshold of patients to discomfort arising from the prolapsed internal hemorrhoids.
NO BLEEDING; NO PROLAPSED INTERNAL HEMORRHOIDS; SMALL HEMORRHOIDS
Recommendation: NO OPERATION; watch and wait; supportive management such as warm sitz bath and avoiding constipation; medications such as pain killers; laxatives; etc.
Prevent hard dry stools which make hemorrhoids worse Might reduce bleeding and other hemorrhoid symptoms Needs to be taken with plenty of water (8 glasses of water a day) Your doctor might suggest starting with a small dose and then increasing over time
May dry or tighten skin around the anus Zinc oxide also protects skin from irritationArea must be gently cleaned and allowed to dry before using Can apply after a sitz bath (soaking in warm, shallow water) Witch hazel wipes or unscented baby wipes can be used to clean the anus after a bowel movement
Steroid cream
Hydrocortisone rectal cream (sample brand name: Preparation H hydrocortisone)
Reduces swelling, and pain caused by hemorrhoids Do not use for longer than a week Do not use at all if you are pregnant unless your doctor or nurse tells you to
Medicines to shrink hemorrhoids
Phenylephrine ointment or suppository (sample brand names: Preparation H, Rectacaine)
Phenylephrine shrinks swollen hemorrhoids, and relieves itching and discomfort for a few hours Area must be gently cleaned and allowed to dry before applying
Benzocaine, dibucaine, and lidocaine can help with pain and itching, but should not be used without talking to a doctor first. They should only be used once in a while, in small amounts.
This table lists some examples of over-the-counter treatments for hemorrhoids. There are many more brand-name and generic versions available, too. Read all labels to make sure you’re not using too much of one ingredient.
Do not use over-the-counter treatments for more than one week without speaking to your doctor. They can damage your skin.
Follow instructions carefully – for example, it’s important to clean and dry your skin before using creams or ointments. You can use an unscented baby wipe to clean your anus after a bowel movement.
If you have rectal bleeding, or if your bowel movements look like tar, see your doctor or nurse. These problems could be caused by something other than hemorrhoids. You should also see your doctor or nurse if your hemorrhoid symptoms still bother you after you have tried taking care of them yourself.
ROJ-PBL-MedSurg = ROJoson Problem-based Learning in Medicine and Surgery
May 9, 2022
I have always wondered the origin of the word “Penrose” on Penrose drain. In my medical writings, I would usually call the drain simply as a rubber drain.
Here is my Internet search:
The Penrose drain is named after American gynecologist Charles Bingham Penrose (1862–1925).
That’s it.
Penrose is the surname of an American gynecologist who popularized the use of a rubber drain in surgery.
Penrose drain is simply a rubber drain – soft, flexible, rubber, usually made of latex, which is radio-opaque on x-ray. It comes in different sizes. It is usually used as a surgical drain to prevent the buildup of fluid in a surgical site.
Practically, all the medical supply stores carry the word “Penrose” in naming the rubber drains.
In the Philippines, as of May 2022, the price is about P75.00 to P80.00 per piece.
(Note: tube drains have a quote of P1,325.00 – Pana-Vac.)
There is still a place in the use of rubber drains or Penrose drains in managing surgical wounds. Nowadays, however, a lot of surgeons are using tube drains more frequently than rubber drains. Hopefully, in the future, I will be able to discuss the indications and selection of the two kinds of drains.
ROJ-TPOR-SURG = Reynaldo O. Joson’s Thoughts, Perceptions, Opinions and Recommendations on Surgical Health Issues
Intended audience: General Surgeons, General Surgery Residents and Primary Health Care Physicians
TPORs – ROJoson’s thoughts and perceptions on an identified surgical health issues with inputs from personal experience and information from Internet followed by opinions and recommendations on how to respond to the issue.
Surgical Health Issues on Gallbladder Polyps
Should a cholecystectomy be recommended for all patients with an incidental asymptomatic gallbladder polyp/s seen on ultrasound?
What are the comparative benefit-risk-cost-availability data and information that will guide the patients and the physicians in the selection of options (to do cholecystectomy or not for incidental asymptomatic gallbladder polyp/s on ultrasound)?
If you were the patient, what option will you choose given the comparative benefit-risk-cost-availability data and information? You may include your reasons for the choice.
Real-life Situations and Challenges on Gallbladder Polyps
With the widespread use of ultrasound of the abdomen as well as other imaging procedures like CT Scan and MRI, both for screening and diagnostic purpose, asymptomatic gallbladder polyps are frequently detected on an incidental basis.
A common question is what to do with the reported incidental gallbladder polyp/s that is / are not associated with other gallbladder pathology like gallstones.
Note1: a specially common real-life situation in the Philippines consists of seafarers undergoing screening abdominal ultrasound and upon finding of gallbladder polyp/s, they are told to see a general surgeon for management – usually a cholecystectomy is recommended. The question or challenge is: should a cholecystectomy be done in seafarers with asymptomatic gallbladder polyp/s in which there are no associated other gallbladder pathology like stones?
Note2: People undergoing “executive checkups” may encounter the same situation – finding of asymptomatic gallbladder polyp/s on ultrasound – and the same challenge – what to do with the polyps, to do cholecystectomy or not?
Should a cholecystectomy be recommended for all patients with an incidental asymptomatic gallbladder polyps seen on ultrasound?
The answer is an outright NO. Cholecystectomy should NOT be recommended for ALL patients with an incidental asymptomatic gallbladder poly/s seen on ultrasound.
The polyp/s reported on ultrasound should be further evaluated by the clinician-surgeon on the risk for gallbladder cancer. As a general rule, if the risk of gallbladder cancer is low, then NO cholecystectomy is recommended, just watch and wait or surveillance. If the risk is significant or high, then cholecystectomy is recommended.
Aids in assessing the risk for gallbladder cancer include size of the polyp/s (1 cm or greater is considered to be carrying a significant risk – some authors would put 1.5 cm as the cut-off size); the morphology, whether sessile or pedunculated or round (if there is a report of sessile morphology, this should be regarded as significant risk); and the number or quantity of polyp/s (multiple carries a low risk).
Examples of scenarios and usage of the characters of polyp/s in general risk assessment:
1) solitary polyp, sessile, 1cm or greater – high risk for gallbladder cancer
2) Multiple, non-sessile (round or pedunculated) and less than 1 cm in size – very low risk for gallbladder cancer
3) Solitary, non-sessile (round or pedunculated) and less than 1 cm in size – still a low risk for gallbladder cancer because morphology and size carry more weight or have higher predictive values than quantity.
Annotation1: The incidence of gallbladder cancer in gallbladders polyps should be taken into consideration in the risk assessment also. Some reported 1%. Some reported 5% depending on the series. Highest reported so far is 5%.
Annotation2: The morphology carries the heaviest weight in risk assessment compared to size and quantity. A report of sessile morphology is alarming, a red flag. This is supported by the following findings in a study: {http://www.scielo.org.co/scielo.php?pid=S0120-99572020000400410&script=sci_arttext&tlng=en}
The probability of malignancy was 13.9% in sessile polyps <10mm.
If the polyp was solitary and sessile, the probability of malignancy was 24.8%.
What are the comparative benefit-risk-cost-availability data and information that will guide the patients and the physicians in the selection of options (to do cholecystectomy or not for incidental asymptomatic gallbladder polyps on ultrasound)?
Start with quantifying the degree of certainty or probability of the primary and secondary clinical diagnoses based on the scenario data and information.
Scenario 1: Gallbladder polyps – multiple, non-sessile (round or pedunculated) and less than 1 cm in size – very low risk for gallbladder cancer
Primary clinical diagnosis: BENIGN gallbladder polyp, 98-99% degree of certainty
Annotations on quantification of degree of certainty of clinical diagnosis:
Of the 5482 gallbladder polyps reported, malignancy had an incidence of 0.57% (~1%). [The risk of malignancy in ultrasound detected gallbladder polyps: A systematic review – 2016] {https://www.sciencedirect.com/science/article/pii/S1743919116302709}
Some papers reported that among the gallbladder polyps, 95% are pseudopolyps (therefore, benign) and 5% are true polyps. Classified under true polyps are the adenomatous and carcinomatous polyps with the former being more common. Another paper reported only 0.60% for true polyps. [The risk of malignancy in ultrasound detected gallbladder polyps: A systematic review – 2016] {https://www.sciencedirect.com/science/article/pii/S1743919116302709}
Comparative benefit-risk-cost-availability data and information on the 2 options
Options
Benefit
Risk
Cost
Availability
Cholecystectomy
To be able to know for sure the true diagnosis of the gallbladder polyps.
To be able to catch gallbladder cancer early enough if cancer is truly present (because of the 1% to 2% chance of gallbladder cancer)
After operation, no more concern or worry for future gallbladder diseases as the GB has been totally removed already (assuming the GB cancer is also curatively resected).
Risk of operation and anesthesia mortality and complications.
-Injury to common bile duct (most serious – less than 1%) -Infection -Bleeding -Bile Leak -Injury to nearby organs like liver and bowel -Blood clots (deep vein thrombosis) -Pneumonia -Scar and numb feeling at incision site -Hernia -Others
Cost of operation including hospital expenses
Rough estimate and range depending on government or private hospitals and attending physicians:
Ballpark figures: P50K to P200K or even more (depending on hospital and attending physicians)
May or may not be covered by health insurances like PhilHealth and HMOs.
NOTE: the prices are variable.
Procedure of cholecystectomy readily available (open cholecystectomy and laparoscopic cholecystectomy)
Open cholecystectomy more readily available though.
No cholecystectomy – just monitor polyps and symptoms – watch and wait stance
No operation is done as it is not needed or not strongly indicated.
1-2% chance of gallbladder cancer not discovered and treated now
*No risk for cholecystectomy operation and anesthesia mortality and complications
Cost of serial ultrasounds to monitor polyps – once a year for 2 years at least (P5K for 2 ultrasounds)
*NO cost of operation with hospital expenses
NOTE: the prices are variable.
Procedure for ultrasound readily available
Scenario 2: Gallbladder polyp – solitary, sessile and more than 1 cm in size – high risk for gallbladder cancer
To be able to catch gallbladder cancer early enough as there is already a high probability of gallbladder cancer being present.
In case it turns out not be cancer, it is acceptable to err on the side of commission rather than omission.
After operation, no more concern or worry for future gallbladder diseases as the GB has been totally removed already (assuming the GB cancer is also curatively resected).
Risk of operation and anesthesia mortality and complications.
-Injury to common bile duct (most serious – less than 1%) -Infection -Bleeding -Bile Leak -Injury to nearby organs like liver and bowel -Blood clots (deep vein thrombosis) -Pneumonia -Scar and numb feeling at incision site -Hernia -Others
Cost of operation including hospital expenses
Rough estimate and range depending on government or private hospitals and attending physicians:
Ballpark figures: P50K to P200K or even more (depending on hospital and attending physicians)
May or may not be covered by health insurances like PhilHealth and HMOs.
NOTE: the prices are variable.
Procedure of cholecystectomy readily available (open cholecystectomy and laparoscopic cholecystectomy)
Open cholecystectomy more readily available though.
No cholecystectomy – just monitor polyps and symptoms – watch and wait stance
Operation is not needed and is not done because the polyp may just be benign.
However, only time will give the true diagnosis.
Error of omission if the polyps turn out to be really gallbladder cancer
*No risk for cholecystectomy operation and anesthesia mortality and complications
Cost of serial ultrasounds to monitor polyps – once a year for 2 years at least (P5K for 2 ultrasounds)
*NO cost of operation with hospital expenses
NOTE: the prices are variable.
Procedure for ultrasound readily available
If you were the patient, what option will you choose given the comparative benefit-risk-cost-availability data and information?You may include your reasons for the choice.
How I will decide:
I will study carefully the data and information comparing the 2 options in terms of benefit, risk, cost and availability. I will ask for more data and information and clarification if needed.
I will consider the degree of certainty in the diagnosis given to me by my physician with good bases and accepting that there is no such thing as 100% certainty.
I will put heaviest weight on the INDICATION or the valid reason for an option based on my diagnosis.
If there is no clear-cut indication for either options, I will scrutinize the data and information further, putting priority in balancing the benefit and risk than the cost and availability and then decide based on my personal values (but I have to control my hidden biases and mindset). In particular, I have to modulate my orientation on being a maximalist or a minimalist. Briefly, MORE IS BETTER for a maximalist orientation. LESS IS MORE for a minimalist orientation, meaning avoiding treatment if at all possible; if that is not possible, doing the essentials and most conservative approach as much as possible.
The decision is mine. The physician can only assist me in my decision-making.
So, for my decision:
For Scenario 1: NO Cholecystectomy – Just monitor polyps and symptoms – watch and wait stance
For Scenario 2: Cholecystectomy
For other scenarios – I will be guided by the risk assessment using size, morphology and quantity parameters. Among the three, morphology and size take priority. Quantitate the degree of certainty or probability of the primary clinical diagnosis. If the degree of certainty for MALIGNANT polyps is 60 to 80%, I will submit to cholecystectomy. If the degree of certainty for BENIGN polyps is 60 to 80%, I will still do watch and wait stance.
In watch and wait stance, I will use symptom-based monitoring and serial imaging procedures (ultrasound) to monitor the status of the polyp/s.
Annotation: Recommended schedule of serial ultrasoundsurveillance
Schedule of ultrasound surveillance: every 6 to 12 months for 2 years after first diagnosis of BENIGN polyps; once polyps are deemed stable still with BENIGN diagnosis, every 1 to 2 years thereafter or at longer intervals such as 3 to 5 years as indicated.
If there is progressive increase in size of the polyp up to 1cm, or even without reaching 1cm, say 7 or 8 mm, especially if the morphology is sessile, not pedunculated, gallbladder removal operation is strongly recommended.
What to do in the situationofseafarers with asymptomatic gallbladder polyps?
Use the same processes and rationalization in decision-making and in giving advice to the seafarers. If the recommendation is to watch and wait, the physician-surgeon should issue a certificate to this effect.
NOTE1: Some medical clinics screening seafarers will insist on a cholecystectomy for all asymptomatic gallbladder polyps. This is a challenge for physician-surgeons who don’t agree with this policy and procedure of the medical clinics. This is also a challenge for the seafarers who have reasonably chosen wait and watch stance. Possible remedies: 1) the physician-surgeons issue a certificate to the effect that cholecystectomy is NOT needed at the moment (as much as possible, communicate with the medical officer giving official clearance) and/or 2) the seafarers look for another medical clinic which will not insist on a cholecystectomy for all asymptomatic gallbladder polyps.
NOTE2: If the concern of the medical clinics screening seafarers is that the gallbladder polyps will lead to a health problem such as abdominal pain during the seafarers’ tour of duty, this is of smallest probability. The gallbladder polyps are attached to the wall of the gallbladder, not floating in the lumen. They will usually not cause acute symptoms of obstruction as with gallbladder stones.
END OF [ROJ-TPOR-SURG]: Gallbladder Polyps
Additional information on gallbladder polyps that may be useful in problem-solving and decision-making:
A gallbladder polyp is operationally defined as an elevation of the gallbladder mucosa or wall that protrudes into the gallbladder lumen. Outgrowth of the gallbladder mucosa may be another term for elevation. However, outgrowth has a negative connotation compared to elevation. Outgrowth always implies there is a new growth or tumor which is not always the case in gallbladder polyps as will be seen when the different types of polyps are discussed. Note a classification of gallbladder polyps, true polyps and pseudopolyps, supports the use of elevation rather than outgrowth.
It is usually seen and reported in imaging diagnostic procedures like ultrasound, CT Scan and MRI of the gallbladder. The elevation of the gallbladder wall is usually reported as a gallbladder polyp. The latter is a generic phrase for any elevation on the gallbladder wall. It does not specify the exact nature and cause of the elevation that is labelled as polyp.
In actuality, meaning after the gallbladder is removed on the ground of elevation or polyp and after it is examined grossly and microscopically, the latter can be of several types and cause.
It can be a:
Mucosal fold – a redundant mucosal fold or baggy mucosal fold – with no increase in number of cells -producing an elevation of the gallbladder mucosa.
Mucosal hyperplasia – due to increase in number of cells – producing an elevation of the gallbladder mucosa – if there is no identified specific cause, it is just called mucosal hyperplasia – if there is an identified specific cause, such as inflammation, then it is called inflammatory polyp. Inflammatory polyp is a generic term for non-neoplastic (non-newgrowth) mixture of epithelial and stromal components admixed with inflammatory cells.
Cholesterolosis of the gallbladder – deposits on the gallbladder wall of cholesterol esters sticking to the gallbladder wall forming polyp/s.
Bile sludge – a mixture of particulate solids that have precipitated from bile which may attach to the wall of the gallbladder producing a picture of polyp/s.
Adenomatous polyp – a benign or non-malignant neoplastic growth (tumorous growth) of glandular elements of the gallbladder mucosa causing elevation of the gallbladder wall.
Carcinomatous polyp – a malignant neoplastic growth (tumorous growth) of gallbladder mucosa causing elevation of the gallbladder wall.
I just mentioned 6 types but there could be more types and other causes.
By the way, on the classification of pseudopolyps and true polyps. The mucosal fold, nonspecific mucosal hyperplasia, cholestorolosis and bile sludge are considered pseudopolyps. The adenomatous polyp and carcinomatous polyp are considered true polyps.
To repeat, a gallbladder polyp as reported in imaging procedures is generic phrase for any elevation on the gallbladder wall. It does not specify the exact nature and cause of the elevation that is labelled as polyp. Since adenomatous polyp and carcinomatous polyp are RARE, the gallbladder polyp reported in imaging procedures is usually benign.
Regardless of size, it is reported that about 95% of gallbladder polyps are benign. A gallbladder polyp less than one centimeter in size reported on imaging procedures will turn out to be gallbladder cancer in only 1% of cases. It is important to look at the size of the gallbladder polyp to see if a gallbladder cancer should be strongly suspected or not. A gallbladder polyp reported on imaging procedures that is 1cm or greater in size should be considered for operation.
The reported gallbladder polyps on imaging procedures may be solitary or single or may be multiple. There is a higher risk for gallbladder cancer if the polyp is solitary compared to multiple.
Thus, the number and the size are important information in the specific diagnosis of the gallbladder polyp. Another information, if present, will be helpful – morphology. If pedunculated or round, big chance it is benign. Sessile (with broad base) morphology is alarming, a red flag.
Symptom wise, gallbladder polyps typically cause NO noticeable symptoms and are often detected on imaging studies done for other reasons. Unless a gallbladder polyp turns out to be gallbladder cancer and is growing in size and invading the adjacent organs like the liver, usually there are no symptoms.
Some pictures
Multiple mucosal hyperplasia or hyperplastic polyps Multiple mucosal hyperplasia or hyperplastic polypsCholesterolosesBile sludges forming pseudopolypsCholesteroloses with stoneCholesteroloses with stoneGallbladder stonesGallbladder cancerMy usual certificate – clearance.Sample of certificate – clearance
What are the tumor markers usually being used for pancreatic cancer?
Among the many tumor markers, carbohydrate antigen 19-9 (CA 19-9) has a relatively high sensitivity and specificity for pancreatic and biliary tract tumors1,2. According to previous studies, the sensitivity of CA 19-9 in diagnosing pancreatic cancer ranges between 79% and 95%, and the specificity ranges between 82% and 91%3,4.
CA 19-9 stands for carbohydrate antigen 19-9.
What is the significance of CA 19-9?
CA 19-9 was a better predictor of recurrence compared to CEA.
J Clin Oncol
. 1988 Mar;6(3):462-8.
doi: 10.1200/JCO.1988.6.3.462.
Evaluation of the utility of a radioimmunoassay for serum CA 19-9 levels in patients before and after treatment of carcinoma of the pancreas
Our data indicate that a normal early postoperative CA 19-9 score is a relatively favourable prognostic index in patients who undergo radical surgery for pancreatic cancer and that the CA 19-9 test can be used, as an early marker of recurrence, in monitoring these patients.
Based on the results from multicenter randomized controlled trials, primarily initiated by the European Study Group of Pancreatic Cancer (ESPAC), adjuvant chemotherapy has become the gold standard after upfront resection, while adjuvant chemoradiotherapy is not recommended. Combination chemotherapy with gemcitabine and capecitabine was shown to significantly prolong median overall survival after resection compared to monotherapy with either gemcitabine or 5-fluorouracil/folinic acid. Recent data from the French-Canadian Uni-Cancer GI PRODIGE 24/CCTG PA.6 trial showed that adjuvant poly-agent chemotherapy with modified FOLFIRINOX achieved median survival times of 54.4 months in selected patients.Despite improved survival times after resection followed by adjuvant chemotherapy, however, recurrence occurs still in more than 75% of patients within the first 2 years after resection.
but even in patients with R0 resected tumours, 5-year survival is no more than 20% with a median survival between 12 and 20 months.[2–5]
Randomized controlled Phase III trials have demonstrated that adjuvant chemotherapy with gemcitabine improves median disease-free survival of R0 as well as of R1 resected pancreatic adenocarcinoma from 5–7 months to 10–13 months
Adjuvant and neoadjuvant therapy for pancreatic cancer
Pancreatic cancer still remains a major cause of cancer-related mortality; however, there is a slight but continuous improvement in survival over the past 2 decades. Progress in chemotherapy has contributed to the survival improvement in patients with any stage of pancreatic cancer. In this review, we summarize the currently available evidence regarding adjuvant and neoadjuvant therapy with a focus mainly on randomized controlled trial. The median overall survival in resected pancreatic cancer patients has significantly improved to 22.8 to 54.4 months with the use of adjuvant therapy from 11 to 20.2 months with a strategy of observation only. Recent data from randomized trials support the use of neoadjuvant therapy for patients with resectable or borderline resectable pancreatic cancer. But given a variety of neoadjuvant regimens and different definitions of resectability status, data should be interpreted with caution. Several other trials are ongoing and will provide further evidence.
How soon after Whipple surgery does chemo start?
You should be given time to recover properly from your surgery before starting chemotherapy, as you need to be well enough for six months of chemotherapy. Chemotherapy may start up to 12 weeks after your surgery.
Conclusion
Completion of all six cycles of planned adjuvant chemotherapy rather than early initiation was an independent prognostic factor after resection for pancreatic adenocarcinoma. There seems to be no difference in outcome if chemotherapy is delayed up to 12 weeks, thus allowing adequate time for postoperative recovery.
Median survival even with sophisticated treatment – below one year (12 months).
Recommendations based on the decision tree: no anti-cancer treatment; best supportive care with pain control; preparation for curtain call with advance healthcare directive.
ROJoson Thoughts, Perceptions, Opinions and Recommendations
Problem-based Learning in Surgery 