- Choledochal cyst:(types)
type I: dilatation of CBD
Ia-->cystic.
Ib-->saccular.
Ic-->fusiform.
type II: Choledochal diverticle.
type III: Choledochocele.
type IVa: Dilatation of extra & intra hepatic biliary ducts.
type IVb: Dilatation of multiple sections of extrahepatic duct.
type V: Caroli's syndrome.

- Congenital extrahepatic biliary atresia (types):
type I: atretic CBD.
type IIA: atretic CHD.
type IIB: atretic CBD and CHD.
type III: atretic CBD, CHD, RHD&LHD

Klatskin tumour is classified as 4 types—
I: Just at or below the confluence;
II: At the confluence.
III: at the confluence extending
along the RHD.
IV: at the confluence extending along the LHD.

Mirizzi syndrome:-
Type I : Compression of CBD without lumen narrowing.
Type II : Compression causing CBD lumen narrowing.
Type III : Compression causing CBD wall necrosis.
Type IV : Cholecysto-choledochal fistula.

Pancreatic pseudocyst

◼️This refer to the collection of pancreatic secretions in a well defined wall of granulation tissue or fibrous tissue.

◼️It forms after trauma, acute pancreatitis or chronic pancreatitis, basically anything that lead to duct disruption and escape of pancreatic secretions, it requires 4 weeks or more from the index event for the wall to fully mature.

◼️Most pseudocysts are located in the lesser sac, unusual locations do occur however like in the spleen or even the chest, but this is rare, most do go away on their own, but those over 6 cm, lasting over 12 weeks or occur due to chronic pancreatitis are unlikely to resolve spontaneously.

◼️When appropriate drainage should be done, this can be done by simple percutaneous aspiration or by cystogastrostomy which are nowadays usually done by endoscopy.

◼️Above table lists possible complications of pseudocysts.

#Surgery

Nomenclature

◼️Halsted mastectomy = involve removal of breast, pectoralis major and minor, with axillary nodes fascia and fat. No longer done.

◼️Modified 'patey' mastectomy = en bloc removal of breast, skin (centre of which overlies the tumor but always includes the nipple), axillary dissection.

◼️Wide local excision = removal of the tumor with a rim of healthy tissue of atleast 1 cm.

◼️Quadrantectomy = removal of the segment containing the tumor.

◼️QUART = combination of quadrantectomy, axillary dissection and radiotherapy.

#Breast

Indications for mastectomy

Recently there has been a gradual shift towards more conservative techniques, clinical trials has shown that mastectomy has equal efficacy to local excision and radiotherapy, therefore nowadays mastectomy is strictly indicated only in the following conditions:

◼️Large tumor in relation to the size of the breast (small breast).

◼️Central tumor beneath or involving the nipple.

◼️Multifocal especially seen in lobular carcinoma.

◼️Local recurrence.

◼️Patient preference.

#Breast

Paget disease of the nipple

◼️This is an eczema like condition of the nipple and areola.

◼️It is indicative of an underlying breast carcinoma.

◼️The nipple becomes slowly eroded until its completely obsecured (see image above black arrow) , if left, the underlying carcinoma will sooner or later become clinically evident.

◼️The pathophysiology is uncertain, according to the migratory theory, malignant cells travel along the duct system and eventually reach the nipple and areola, the motility of these cells being induced by motility factors acting through HER2/NEU receptors.

◼️Microscopic picture include presence of large ovoid malignant cells with abundant pale cytoplasm in the malpighian layer of epidermis.

◼️It should be suspected strongly when a presumed eczema of the nipple fails to respond to local treatment, whenever in doubt, biopsy of the nipple should be obtained to confirm the diagnosis.

#Breast

Aetiologic factors in breast cancer

◼️Geographic

Breast cancer is more common in developed western counteries, it account for 3-5% of all deaths, whereas in developing counteries the incidence is lower and account for 1-3% of all deaths. It was found to be rare in japan.

◼️Age

Breast cancer is extremely rare below the age of 20 years, but thereafter, the risk steadily increasea until it becomes 20% at 90 years.

◼️Gender

Males represent less than 0.5% of all cases of breast cancer.

◼️Genetic

Breast cancer is more common in women with a family history of breast cancer,, breast cancers that are due to a specific mutation represent about 5% of all cases, and they will be discussed later in details.

◼️Diet

It was found that there is a link to diets with low phytoestrogens, also high alcohol consumption increase the risk.

◼️Endocrine

Estrogenic drive seems to increase the risk of breast cancer, it was found that nulliparous women are more likely to have breast cancer, also having the first child at an early age is protective, breastfeeding in protective, also late menarche and early menopause seem to be protective.
The role of oral contraceptive pills and hormonal replacement therapy is controversial, it seems that the benefits from these treatments outweight the small putative risk.

#Breast

Phyllodes tumor

◼️Previously known as serocystic disease of Brodie, but also known as cystosarcoma phyllodes.

◼️They may reach massive size (see picture above), and may cause pressure necrosis and ulceration of the overlying skin (note the ulcerations in the picture above), despite all this they remain mobile on the chest wall, and you can insert a probe between the tumor and the skin (usually not fixed).

◼️Phyllodes tumors are usually of the benign type,, only very rarely they are malignant.

◼️Histology is variable, some tumors show low malignant potential, resembling a fibroadenoma, some show high mitotic index which is worrying.

◼️The name cystosarcoma phyllodes, is really out of character, because these tumors are rarely cystic, and very rarely act like a malignant sarcoma.

◼️Treatment can be done by enucleation or wide local excision, but if the tumor is massive, recurrent or of the malignant type, mastectomy is indicated.

#Breast

Duct ectasia/Periductal mastitis

◼️The pathology, is a dilated duct with surrounding periductal inflammation.
◼️The pathogenesis is unclear, the classic event is that dilatation of a large lactiferous duct takes place, then a green or brown secretion fills up the dilated duct, and becomes stagnant, it may discharge from the nipple.
◼️This stagnation initiate irritation of surrounding tissues, and lead to periductal mastitis, abscess formation (see figure yellow arrow), this abscess may open into the skin leading to a fistula (black arrow).
◼️Sometimes these inflammatory changes causes an indurated subareolar mass, which mimics carcinoma.
◼️Eventually, fibrosis takes place and causes a slit like nipple retraction (white arrow).
◼️Smoking clearly increases the risk, some say because it causes an arteriopathy which is an aetiologic factor, others say that it increase virulence of commencal bacteria, either ways, cessation of smoking clearly increase chance of long term cure.

#Breast

Mondor's Disease

◼️The above image is a mondor's disease under the right breast.

◼️It is a thrombophlebitis of the superficial veins of the breast and anterior chest, also reported to involve the arm.

◼️In absence of infection or injury, the cause of this disease is obsecure.

◼️The Pathognomonic feature, is a thrombosed subcutaneous cord of vein usually attached to the skin, when the skin overlying the breast is stretched, a narrow shallow groove appear along side the cord.

◼️Differential diagnosis include lymphatic permeation from an occult breast carcinoma.

◼️No treatment other than restricting arm movement is needed, it resolve on its own in few months without complication, recurrence or deformity.

◼️Some case reports suggested association of mondor's Disease with breast cancer, although this is probably a coincidental event.

#Breast

TNM staging and Manchester staging of breast cancer.

#Surgery

Manchester staging of Breast cancer:

Stage I:
-Mobile tumour in the breast; no deeper fixation; skin if involved lesser the size of the tumour; lymph node spread is absent.

Stage II:
-Same as stage 1 with mobile discrete axillary nodes.

Stage III:
-Fixed to pectoralis major or skin involvement more the tumour size or fixed/adherent node.

Stage IV:
-Tumour fixed to chest wall, involvement same or opposite supraclavicular nodes, opposite axillary nodes, opposite breast, cancer en cuirasse, distant blood spread.

Note:
-Manchester staging and Columbia classification are obsolete (not used now).

#Surgery

Glasgow vs Ranson criteria in AP.

#Surgery

Indications for surgery in AAA:
-Asymptomatic aneurysm more than 5.5 cm.
-Growth rate more than 0.5 cm/year.
-Painful, tender aneurysm.
-Thrombosed aneurysm, aneurysm with distal emboli.

Indications for surgery in PAD:
-Claudication.
-Rest pain.
-Ischemic ulceration.

•ACUTE GASTRIC DILATATION

-It is an enormous acute dilatation of stomach with atonic gastric wall without peristalsis.
-Stomach distends enormously occupying most of the abdomen and pelvis causing sequestration of lots of fluid resulting in hypovolaemia.

#Surgery
#Stomach

•Causes of Acute Gastric dilatation:

1-After major surgery (abdomen,. neurosurgery).
2-Trauma, burns.
3-Retroperitoneal haematoma.
4-Electrolyte imbalance.
5-Other causes: Anorexia nervosa, bulimia, polyphagia, drug abuse, diabetes, anaesthesia, debilitating diseases, spinal cord diseases, muscle dystrophy.

#Surgery
#Stomach

•HYPERTROPHIC PYLORIC STENOSIS

-There is increased risk of developing the condition if new- born gets erythromycin or azithromycin in first 14 days after birth.

#Medicine
#Pediatrics

•Ultrasound abdomen (very useful) in PS:

-Doughnut sign.
-Pyloric muscle 4 mm or more in thickness.
-Length of pyloric canal >14 mm.
-Cervix sign on long avis, target sign on short axis.

#Medicine
#Pediatrics