Ten Commandments of Safe and Optimum Neck Dissection

Zeal to Heal

Post-pneumonectomy Empyema Due to Necrosis and Perforation of a Herniated Stomach Abstract Pleural complications after pneumonectomy occur not only in the early postoperative period but also several years after surgery. Post-pneumonectomy empyema (PPE) is such a possible complication that must be recognized and adequately treated. Sometimes the management of PPE can be extremely challenging because of an abnormal disease presentation and the critical condition of the patient. Herein, present you a unique case of an incarcerated diaphragmal hernia with stomach perforation and necrosis in a post-pneumonectomy patient with development of PPE.

A Patient with Synchronous Primary Hepatocellular Carcinoma and Primary Pancreatic Ductal Adenocarcinoma Abstract The incidence of synchronous double primary malignancies is rare. There were only two cases with synchronous hepatocellular carcinoma (HCC) and pancreatic cancer has been reported so far (J Surg Case Rep 2017(9):rjx182, 2017; Indian J Palliat Care 20:53–6, 2014). Whether double primary malignancies to be operable is an interesting and important issue for surgeon. Here, we report a rare case of synchronous double primary malignancies of the liver and pancreas received simultaneous hepatic segmentectomy and pancreaticoduodenectomy.

Perforation of Cecum Secondary to Foreign Body—Toothpick Abstract Intestinal perforation from foreign bodies is not uncommon. Toothpick perforation of the cecum is rare both site wise and as an etiology of perforation involving the large intestine. We report a case involving a 65-year-old female whose presentation was with nausea, vomiting, and lower abdominal pain of 4 weeks duration. Clinical examination at presentation revealed tenderness in the right iliac fossa with peritonism. Blood results showed marginally elevated inflammatory markers. Computerized tomography (CT scan) of the abdomen and pelvis showed localized perforation of the cecum. Laparoscopy showed cecal perforation adjacent to the ileocecal valve; hence, a right hemicolectomy was performed. Histopathological examination confirmed the above finding. Foreign body perforation of large intestine, although rare, should be a differential for acute abdominal pain. A thorough history, examination, and pertinent imaging are vital to arrive at an early diagnosis and hence management plan.

Aggressive Mucinous Carcinoma of Male Breast Abstract We report of a mucinous carcinoma of the breast in a 62-year-old male, who presented with left breast mass and incisional biopsy scar. Incisional biopsy showed invasive mucinous carcinoma with endocrine differentiation. Patient underwent a simple mastectomy and sentinel lymph node biopsy (SLNB). In definitive pathologic examination, tumor showed estrogen- and progesterone-positive and her2-neu-negative receptor status. This was followed by adjuvant chemotherapy. After 2 weeks of the first cure chemotherapy treatment, patient admitted with respiratory distress and diagnosed as having thoracentesis requiring massive pleural effusion. In the detailed examination, multiple hepatic metastases were detected. In this report, we present a male patient with mucinous breast carcinoma and multiple distant metastases.

Radical Mastectomy SANS Axillary Lymph Node Dissection for Large Phyllodes Tumor: a Guarantee Against Recurrence Abstract Phyllodes tumor of the breast is a rare mixed tumor of epithelial and mesenchymal origin with an incidence of less than 1% of all primary breast tumors. This tumor is well known for its high potential for local recurrence ranging in 8–40% of patients. Excision of tumor with a 2-cm margin without raising skin flap along with overlying skin and underlying part of pectoralis major muscle described by our team seems to be a guarantee against local recurrence. It was a prospective cohort study conducted at the Department of Surgical Disciplines, AIIMS, New Delhi, India, from March 2011 to December 2016. Patients with large phyllodes tumor were managed with a “radical mastectomy without axillary lymph node dissection” whereas women with a small lesion were treated with a wide local excision with a 2-cm margin of healthy breast tissue all around the lesion following our surgical technique. Sixty-one women were enrolled in this study. Twenty-nine patients underwent wide local excision, and 32 patients with large, recurrent, or malignant tumors were managed by radical mastectomy without axillary lymph node dissection (ALND) (27 patients) and with ALND in 5 patients with enlarged axillary nodes. None of the patients have developed local recurrence till date with a follow-up period ranging from 2 to 59 months. Excision of tumor with a 2-cm margin without raising skin flap along with overlying skin and underlying part of pectoralis major muscle is a very effective technique to prevent local recurrence.

Risk Factors for Lymph Node Metastasis in Undifferentiated Early Gastric Cancer Abstract The indication for endoscopic resection is differentiated gastric cancer ≤ 2 cm in size without an ulcer, of which the depth of invasion is clinically diagnosed as tumor confined to the mucosa. Endoscopic resection is not indicated for undifferentiated gastric intramucosal carcinoma, which is associated with a high rate of lymph node metastasis. This study aimed to analyze the factors associated with lymph node metastasis and to determine the validity of endoscopic resection in patients with undifferentiated early gastric cancer (EGC). This study included 141 patients who underwent gastrectomy with lymph node dissection for undifferentiated EGC. The clinicopathological findings were retrospectively analyzed to identify the factors associated with lymph node metastasis. According to the depth of tumor invasion, lymph node metastasis was observed in 13 patients (9.2%), including three with intramucosal carcinoma (3.6%) and ten with submucosal invasive carcinoma (17.2%). Univariate analysis identified tumor size (p = 0.038), depth of tumor invasion (p = 0.008), and lymphovascular invasion (LVI) (p = 0.0002) as risk factors for lymph node metastasis. On multivariate analysis, LVI (p = 0.002) was identified as the only independent risk factor for lymph node metastasis. The use of endoscopic resection for the undifferentiated EGC should be considered carefully for patients with LVI because of the risk for lymph node metastasis.

Complex Liver Injury—a Quagmire to a Trauma Surgeon Abstract Non-operative management has become a norm in patients with liver trauma and operative management is guided by hemodynamic status. Introduction of haemodynamic status. Introduction of contrast enhanced computed tomography (CECT) abdomen has made NOM possible by helping in exclusion of other injuries and identification of vascular injuries. Haemodynamic instability is now considered as an only absolute indication for operative intervention in liver injuries. However, liver trauma is associated with a large number of complications in the form of perihepatic abscess, hepatic necrosis, bile leak, etc. Patient’s undergoing operative intervention for liver trauma are more at risk for these complications. As such regular dynamic assessment is required for early identification and management of these complications. We present a case of a complex liver injury in a 27-year-old male who underwent operative intervention for liver trauma and had a varied number of liver trauma associated complications, with enterohepatic fistula as one of the rarest associated complications.

Incidental Lesions Detected in Reduction Mammoplasty Specimens Abstract The incidence of breast lesions detected in reduction mammoplasty specimens varies with patients’ previous history of breast cancer, patients’ age, and the number of submitted pathological sections. The incidence of proliferative lesions with atypia including invasive carcinoma varies in different studies between 0.2% and 1.1%. In a retrospective review, 392 patients who underwent reduction mammoplasty mainly for symptomatic macromastia or breast symmetry were included in this study. All specimens of reduction mammoplasty were submitted for pathological examination and at least four tissue sections were taken for each breast. Among 392 patients, pathological examinations revealed proliferative lesions with atypia in 7 patients (1.7%) and invasive carcinoma in 1 patient (0.2%). Although proliferative lesions with atypia were found to increase in number compared with the patients under 40 years, there was no statistical significance found. Ductal in situ carcinoma was demonstrated in 1 patient (1%) younger than 40 years. Although there is no consensus formed for when to send mammoplasty specimens for pathological analysis or how many numbers of tissue sections to submit, we recommend routine pathological analysis of mammoplasty specimens and submitting at least four tissue sections regardless of patients’ age.