Management of granulomatous lobular mastitis: an international multidisciplinary consensus (2021 edition)

Granulomatous lobular mastitis (GLM) is a rare and chronic benign inflammatory disease of the breast. Difficulties exist in the management of GLM for many front-line surgeons and medical specialists who care for patients with inflammatory disorders of the breast. This consensus is summarized to establish evidence-based recommendations for the management of GLM. Literature was reviewed using PubMed from January 1, 1971 to July 31, 2020. Sixty-six international experienced multidisciplinary experts from 11 countries or regions were invited to review the evidence. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Experts discussed and concluded 30 recommendations on historical definitions, etiology and predisposing factors, diagnosis criteria, treatment, clinical stages, relapse and recurrence of GLM. GLM was recommended as a widely accepted definition. In addition, this consensus introduced a new clinical stages and management algorithm for GLM to provide individual treatment strategies. In conclusion, diagnosis of GLM depends on a combination of history, clinical manifestations, imaging examinations, laboratory examinations and pathology. The approach to treatment of GLM should be applied according to the different clinical stage of GLM. This evidence-based consensus would be valuable to assist front-line surgeons and medical specialists in the optimal management of GLM.

Reasons for Undesirable Pregnancy Outcomes among Women with Appendicitis: The Experience of a Tertiary Center

Background

Although laparoscopic appendectomy increases its popularity today, the answer to the question of whether to perform open or laparoscopic appendectomy during pregnancy is appropriate in many studies, and the choice of surgery depends on the surgeon. Herein, we aimed to evaluate the variables that affect undesirable pregnancy outcomes that occur as a result of appendicitis during pregnancy.

Methods

Seventy-eight pregnant patients with acute appendicitis who underwent laparoscopic or open technique intervention enrolled in this retrospective study. In addition to the demographic structure of the patients, surgical technique, the number of pregnancies, multiple pregnancy status, surgical pathologies, laboratory values, radiological imaging methods, and length of hospital stay were evaluated. The severity of appendicitis was classified according to the pathology results. The patients were divided into two groups according to the outcomes of their pregnancy. Preterm delivery and abortion involved in the study as a single complication section.

Results

The mean age of the pregnant patients was 28.6 ± 5. Of the 78 pregnant women with appendicitis, 47.4% had their first pregnancy, 37.2% had their second pregnancy, and 15.4% had 3 or more pregnancies. The preterm delivery and abortus were 19.5% in the open appendectomy (OA) group and 16.2% in the laparoscopic appendectomy (LA) group. No statistically significant difference was detected in this group in terms of appendicitis pathology triggering preterm delivery or abortion (p 0.075). When white blood count (WBC) and C-reactive protein (CRP) were evaluated by laboratory findings, CRP was found to be statistically significantly higher in patients with preterm birth (p 0.042).

Conclusion

Consequently, acute appendicitis may cause serious intra-abdominal infection and inflammation in addition to the complexity of the diagnosis due to the nature of pregnancy, as well as undesired pregnancy outcomes with the surgical technique, or independently with other variables.

Appendix Neuroendocrine Tumor: Retrospective Analysis of 4026 Appendectomy Patients in a Single Center

Background/Aim

Appendix tumors are mostly incidentally identified in patients who were operated with the diagnosis of acute appendicitis. They are detected in approximately 1% of appendectomy specimens. Neuroendocrine tumors (NETs) account for over 50% of appendix neoplasms. NETs appearing in the appendix can cause carcinoid syndrome. In our study, we aimed to retrospectively examine the clinical features of patients who underwent appendectomy with the diagnosis of acute appendicitis and diagnosed with appendix NET in the postoperative period. Materials/Methods. The records of 4026 patients who were operated with the diagnosis of acute appendicitis between January 2008 and January 2020 at the Department of General Surgery at the Sakarya University Faculty of Medicine, were evaluated retrospectively. Clinical findings, demographic data, surgical findings, and results of the patients with appendix NET, as a result of histopathology, were examined in detail.

Results

16 of 4026 patients were reported as NET. Nine of the patients were male, and seven were female. The average age was 33 (19–49). Any of the patients had no signs and symptoms of carcinoid syndrome. All tumors were located at the tip of the appendix, and the mean tumor diameter was 0.85 cm (0.3–2.5 cm). As a result of pathology, one patient had mesoappendix and one patient had serosa invasion. Right hemicolectomy was applied to both patients. In other patients, meso, serosa, and lymphatic invasion were not detected. Tumor size was 2.5 cm in one of the patients, 1.5 cm in one, and 1.4 cm in the other, and the others were below 1 cm. In the postoperative follow-up, all the patients were discharged on average 2.71 (2–6 days) days without any complications.

Conclusion

Appendix NETs are mostly asymptomatic and localized in a distal third of the appendix. Symptoms are mostly related to tumor size and distant metastases. Clinical behavior and prognosis can best be predicted by tumor size. Complementary hemicolectomy is recommended for tumors larger than 2 cm and tumors smaller than 1 to 2 cm, such as mesoappendix invasion, positive or uncertain surgical margin, high proliferative rate, and angioinvasion. For tumors whose diameter is less than 1 cm, simple appendectomy alone is sufficient.

Intestinal Obstruction due to Bezoar in Elderly Patients: Risk Factors and Treatment Results

Purpose

Bezoars are foreign particles from the accumulation of indigestible materials in the gastrointestinal system and a rare cause of mechanical intestinal obstruction. We aimed at investigating differences in risk factors for the development of intestinal obstruction associated with bezoar in elderly patients.

Methods

Hospital records of patients who underwent surgery associated with phytobezoar between January 2004 and May 2016 were retrospectively evaluated. Patients were divided into two groups [<65 years (Group 1) and ≥65 years (Group 2)]. Data were examined regarding presence of comorbidity, history of abdominal surgery, operation time, bezoar site, surgical technique, length of hospitalization, morbidity, and mortality.

Results

Of 121 patients enrolled, 48 (39.7%) were male and 73 (60.3%) were female (range: 24-86 years). Group 1 consisted of 69 patients aged < 65, while Group 2 consisted of 52 patients aged ≥ 65. Comorbidity was reported in 52 (42.9%) patients (mostly diabetes mellitus, 20.7%), while 60 patients (49.6%) had history of abdominal surgery (mostly peptic ulcer, 27.3%). No statistical differences were found between the two groups in terms of sex, bezoar site, surgical technique preferred, history of abdominal surgical intervention, pre- and postoperative CT examination, morbidity rates, and length of hospitalization. But, ratio of peptic ulcer operations history, presence of total comorbidity, and time of surgery decision was higher in Group 2 patients.

Conclusion

In bezoar-related intestinal obstruction, duration and outcome of treatment are not affected by age distribution. Possibility of bezoar should primarily be considered in elderly patients with history of peptic ulcer operation.

Physiological parameters for Prognosis in Abdominal Sepsis (PIPAS) Study: a WSES observational study

BACKGROUND

Timing and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.

METHODS

This worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.

RESULTS

A total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28-66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4-10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO₂) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0-1, 22.7% for those who had scores of 2-3, 46.8% for those who had scores of 4-5, and 86.7% for those who have scores of 7-8.

CONCLUSIONS

The simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.

Treatment results of small bowel perforations due to unusual causes

Objectives:

Although non-traumatic Small Bowel Perforations (SBPs) are rare, they have high rates of morbidity and mortality in case of late presentation. Aetiological factors vary across different geographical regions. In this paper, SBPs caused by anything other than trauma and other well-known causes are presented and the current literature is reviewed.

Methods:

The study was conducted at General Surgery Clinics of two different tertiary university hospitals between January 2008 and September 2016. The authors directly involved in managing the patients. This study was approved by the ethical institutional board and was performed at the Department of General Surgery, School of Medicine, Sakarya University. The medical records of patients retained in both hospitals are electronic. Medical records of subjects who had undergone emergency operations with a prediagnosis of acute abdomen in single center, and were determined to have SBPs due to unusual causes, were investigated retrospectively. Patients with aetiological factors such as trauma, mesenteric vascular disease, internal and external hernias, intra abdominal adhesions, inflammatory bowel diseases, and iatrogenic causes were excluded.

Results:

In total, 35 patients were evaluated, 20 (57.1%) males and 15 (42.9%) females. The mean age of the cases was 51.6 (18–88) years. Mean time until admission at the hospital was 1.4 days (range 0.25–7 days). The most frequent aetiological factors were various malignancies (10 cases, 28.5%) and perforation of Meckel’s diverticulum (8 cases, 22.8%). It was surprising to detect a considerable rate of perforation due to bezoars (6 patients, 17.1%).

Conclusions:

Post-operative consequences of SBPs due to unusual causes are similar with those related to common, known causes. Factors affecting the clinical course are presentation time and patients’ clinical status in admission, not aetiology.

Prospective Observational Study on acute Appendicitis Worldwide (POSAW)

BACKGROUND

Acute appendicitis (AA) is the most common surgical disease, and appendectomy is the treatment of choice in the majority of cases. A correct diagnosis is key for decreasing the negative appendectomy rate. The management can become difficult in case of complicated appendicitis. The aim of this study is to describe the worldwide clinical and diagnostic work-up and management of AA in surgical departments.

METHODS

This prospective multicenter observational study was performed in 116 worldwide surgical departments from 44 countries over a 6-month period (April 1, 2016-September 30, 2016). All consecutive patients admitted to surgical departments with a clinical diagnosis of AA were included in the study.

RESULTS

A total of 4282 patients were enrolled in the POSAW study, 1928 (45%) women and 2354 (55%) men, with a median age of 29 years. Nine hundred and seven (21.2%) patients underwent an abdominal CT scan, 1856 (43.3%) patients an US, and 285 (6.7%) patients both CT scan and US. A total of 4097 (95.7%) patients underwent surgery; 1809 (42.2%) underwent open appendectomy and 2215 (51.7%) had laparoscopic appendectomy. One hundred eighty-five (4.3%) patients were managed conservatively. Major complications occurred in 199 patients (4.6%). The overall mortality rate was 0.28%.

CONCLUSIONS

The results of the present study confirm the clinical value of imaging techniques and prognostic scores. Appendectomy remains the most effective treatment of acute appendicitis. Mortality rate is low.

An Endoscopic Nasomediastinal Approach to a Mediastinal Abscess Developing after Zenker's Diverticulectomy

Zenker's diverticulum is the most frequent symptomatic diverticulum of the esophagus, but the prevalence is <0.1%. The optimal treatment is surgery. Here, we present a nasomediastinal drainage approach to treatment of a mediastinal abscess, developing in the late postoperative period and attributable to leakage from the staple line.

Topical Steroids Are Effective in the Treatment of Idiopathic Granulomatous Mastitis

BACKGROUND

Idiopathic granulomatous mastitis (IGM) is a rare, benign, and chronic disease of the breast. Despite the various treatment approaches described for this disease, a gold standard treatment modality has not yet been defined. In this study, the effect of topical steroids was reviewed and assessed in patients with IGM.

METHODS

The records of patients with IGM who were treated only with topical steroids were retrospectively reviewed. Patients were grouped as "completely healed," "inadequately healed," "stable," "worsened," or "recurred" if they had once healed but their symptoms returned. Patients whose skin changes were completely ameliorated were considered "completely healed."

RESULTS

All of the patients were women, and the average patient age was 35.7 years (range 24-48 years). During the average follow-up of 37.2 months (range 12-72 months) in patients who received only topical steroid treatment, recurrence was observed in three patients (3/28, 10.7 %), and no side effects or steroid-related complications occurred.

CONCLUSIONS

Topical steroids seem to be effective in the treatment of IGM characterized by skin changes. Prospective clinical studies would be useful in determining the clinical efficacy of topical steroids in the treatment of IGM.

Retrospective review of pilonidal sinus patients with early discharge after Limberg flap procedure

The aim of this study was to evaluate the results of cases with pilonidal sinus (PS) disease that underwent Limberg flap (LF) transposition and to compare the short and long-term results of early discharge cases with those in the literature. A total of 345 patients who underwent rhomboid excision and LF transposition for PS were evaluated retrospectively. No major anesthetic or surgical complications occurred. Partial wound dehiscence, localized flap necrosis, hematoma, wound infection, and seroma rates were determined as 4.0, 2.1, 1.5, 3.3, and 3.7% respectively. All patients other than those with a hematoma or localized necrosis were discharged with a drain in place 24 hours after the operation. The recurrence rate was 3.9% after a mean 33.1-month follow-up (range, 6-72 months). As a result, we found that short and long-term results of patients who underwent LF and were discharged 24 hours after the operation were similar to those in the literature. We suggest that patients without postoperative complications, such as hematoma or flap necrosis, can be discharged early.

A retrospective review of patients with non-traumatic spontaneous intramural hematoma

BACKGROUND/AIMS

Non-traumatic spontaneous intramural hematoma of the small intestine is a rare clinical condition, most commonly caused by over-anticoagulation. In this study, the clinical approach algorithm for patients diagnosed with a spontaneous isolated intramural hematoma of the small intestine associated with over-anticoagulation and the long-term outcomes of the patients are presented.

MATERIAL AND METHODS

The records of patients who were diagnosed with intramural hematoma in 3 different medical faculty hospitals between 2007 and 2011 were retrospectively analyzed. After excluding patients with trauma history, hematoma in organs other than the small intestine, and with etiological factors other than over-anticoagulation, 15 patients with an isolated intramural hematoma of the small intestine were evaluated within the scope of the study.

RESULTS

The sites of first admission were emergency departments for 10 patients (66.6%) and other clinics for 5 patients (33.3%). Thirteen patients (86.6%) received medical treatment and two patients (13.3%) underwent surgical treatment. During the hospitalization period, a total of two patients (13.3%) died. Out of the 11 patients with an average follow-up of 22 months (range: 4-48 months), no patient had a relapseof intramural hematoma and three patients (27.7%) died due to reasons not related to intramural hematoma.

CONCLUSION

Intramural hematoma diagnosis should be known by all physicians, because the site of first admission may be different clinics, since the clinical presentation begins with non-specific complaints. Early and accurate diagnosis by non-invasive methods will preclude unnecessary surgical interventions.

A rare etiology of acute abdominal syndrome in adults: Gastric volvulus - Cases series

INTRODUCTION

Gastric volvulus is a rare surgical emergency with a high mortality rate that requires urgent surgical management.

PRESENTATION OF CASE

A 19-year-old male and 51-year-old female patient underwent emergency surgery with a prediagnosis of acute abdomen syndrome, and a 60-year-old female patient underwent elective surgery due to diaphragmatic hernia. Abdominal exploration revealed gastric volvulus together with perforation in received emergency surgery patients, and a mesenteroaxial gastric volvulus due to diaphragmatic defect in third patient.

DISCUSSION

Gastric volvulus is classified into four subgroups depending on the mechanism of development, and organoaxial form is the most common type of gastric volvulus. The most challenging step in diagnosing gastric volvulus is the consideration of this diagnosis.

CONCLUSION

Preoperative diagnosis is often difficult, and its management involves surgical correction of the pathology followed by institution of resuscitative treatment.

Mean platelet volume as a potential prognostic marker in patients with acute mesenteric ischemia-retrospective study

INTRODUCTION

We investigated prognostic parameters of patients who underwent surgical intervention for acute mesenteric ischemia by evaluating demographic characteristics and laboratory data on admission.

METHODS

The hospital records of 30 patients who underwent surgical interventions due to acute mesenteric ischemia between January 2008 and December 2012, were reviewed retrospectively. The records were investigated with regard to demographic data, the presence of co-morbid diseases, presenting complaints, time elapsed between symptom onset and hospital admission, laboratory findings at admission, findings at surgical exploration, surgical methods used, and treatment outcomes. The patients were divided into two groups, according to death (Group 1) or survival (Group 2), and the two groups were compared in terms of the specified parameters.

RESULTS

Of the patients, 15 were male (50%) and 15 female (50%); their mean age was 71.4 (29-94) years. Abdominal pain was the chief complaint in all patients (100%) and mean time from pain onset to hospital admission was 21 (1-72) h. In abdominal exploration, total small bowel (SB) ischemia and necrosis was found in 6 (20%) patients and other patients had subtotal SB, segmental SB, segmental SB with colon, or isolated colon ischemia. Treatment in 15 patients (50%) ended in mortality. Mean age (p = 0.038), urea (p = 0.002), AST (p < 0.001), ALT (p < 0.001), mean platelet volume (MPV; p = 0.002), and amylase (p = 0.022) levels in Group 1 were significantly higher versus Group 2, whereas Ca (p = 0.024) and albumin (p = 0.002) levels were significantly lower.

CONCLUSIONS

In this study, unlike other parameters that have been shown to be of prognostic significance in mesenteric ischemia, MPV values at presentation were higher among non-survivors than survivors.

Androgen insensitivity syndrome diagnosed in an elderly patient during a strangulated inguinal hernia repair

INTRODUCTION

A strangulated inguinal hernia is a common indication for emergency surgery. In comparison, complete testicular feminization is a rare genetic disease that can present with an inguinal hernia because of ectopically positioned testicles.

PRESENTATION OF CASE

A 70-year-old female was admitted to the emergency service complaining of a painful swelling in the right inguinal region for 1 day. The physical examination indicated a strangulated inguinal hernia and surgery was performed. On exploring the inguinal region, a strangulated indirect inguinal hernia and hard 2×3-cm mass were detected. The histopathological examination of the excised mass showed testicular tissue, and complete testicular feminization (CTF) was diagnosed after further examinations.

DISCUSSION

Androgen insensitivity syndrome (AIS), the most frequent cause of male pseudohermaphroditism. The diagnosis of patients with AIS is usually made at the beginning of the second decade when a healthy person with a female phenotype complains of no menarche. Making a first diagnosis after the 5th decade is extremely rare.

CONCLUSION

While AIS can be diagnosed in early adulthood, cases might not bediagnosed until the patient is of advanced age.

CT findings of patients with small bowel obstruction due to bezoar: a descriptive study

Purpose. The aim of this study was to present the computed tomography (CT) findings of bezoars that cause obstruction in the small bowel and to emphasize that some CT findings can be considered specific to some bezoar types. Materials and Methods. The records of 39 patients who underwent preoperative abdominal CT and subsequent operation with a diagnosis of intestinal obstruction due to bezoars were retrospectively analyzed. Results. In total, 56 bezoars were surgically removed from 39 patients. Bezoars were most commonly located in the jejunum (n = 26/56, 46.4%). Sixteen (41.0%) patients had multiple bezoar locations in the gastrointestinal tract. Common CT findings in all patients were a mottled gas pattern and a focal ovoid or round intraluminal mass with regular margins and a heterogeneous internal structure. Furthermore, some CT findings were determined to be specific to bezoars caused by persimmons. Conclusions. Preoperative CT is valuable in patients admitted with signs of intestinal obstruction in geographic regions with a high bezoar prevalence. We believe that the correct diagnosis of bezoars and the identification of their number and location provide a great advantage for all physicians and surgeons. In addition, some types of bezoars have unique CT findings, and we believe that these findings may help to establish a diagnosis.

Intestinal obstruction due to bezoars: a retrospective clinical study

PURPOSE

The purpose of this study was to compare the results of surgical procedures applied to rare intestinal obstruction cases due to bezoars and to identify effective factors for determining the type of surgical procedure to be applied.

METHODS

The records of 62 patients who had received gastrointestinal surgical treatment due to bezoars were assessed retrospectively. The preoperative characteristics, perioperative findings and postoperative results of cases that had and had not undergone an enterotomy were compared

RESULTS

The average patient age was 57.7 years (range, 26-84 years), and all patients had phytobezoars, except one. The most common location for bezoars was the jejunum (28 cases, 45.1 %). Sixteen cases (25.8 %) had multiple bezoars located in different parts of the gastrointestinal tract. While milking was applied to 26 cases (41.9 %) with small intestinal bezoars, an enterotomy was used to remove bezoars in 23 cases (37 %). More complications tended to be identified in patients who underwent an enterotomy; however, the difference was not significant (p = 0.553).

CONCLUSIONS

The frequency of previous abdominal surgery in patients suffering from an intestinal obstruction due to bezoars causes diagnostic conflict. The location of bezoars in the small intestine should also be considered when deciding the surgical procedure, as well as the physical properties of the bezoars. Our opinion is that conducting the milking procedure should not be insisted on, and that an enterotomy should be conducted when necessary.

Topical steroids to treat granulomatous mastitis: a case report

Idiopathic granulomatous mastitis (IGM) is a rare and chronic benign disease of the breast. Histologically, the disease presents as an intense inflammatory reaction with non-caseated granulomas that are the characteristic symptom of the disease. No consensus exists on the best treatment modality for this disease. In this report, we present a patient with granulomatous mastitis who was treated successfully with low-dose oral and topical steroids. Our aim here is to discuss various approaches for IGM in view of the literature and present treatment with topical steroids, which has not been reported.

Primary small cell carcinoma of the lung presenting with breast and skin metastases

Cutaneous metastases originating from an internal cancer are relatively uncommon in clinical practice, and metastatic lesions to the breast are rarer than those to the skin. Skin metastases of lung cancer, which may be the first sign of the disease, usually indicate progressive disease and a poor prognosis. We describe a 47-year-old male who presented with recurring masses in the lumbar region bilaterally and the right breast. Immunohistochemical findings and radiological imaging suggested lung cancer. This is the first reported case of small cell lung cancer metastasizing to two separate, uncommon sites, the skin and breast.