Gallbladder Polyps Recommended for Operation – SAD

Today, I was sad when I saw a seafarer patient who came in for a 2nd opinion.  He was recommended to have a laparoscopic cholecystectomy.  Ultrasound showed polyps 4 to 6 mm in size with no gallbladder wall thickening and patient is asymptomatic.  He was asked to prepare 120 to 160 thousand pesos for a laparoscopic cholecystectomy.

gb_polyps_lap_chole_2017may18

I am sad because I believe gallbladder polyps, especially those smaller than 1 cm and asymptomatic, need no operation.

I am sad  because I have been advocating a wait and see approach with no operation when not needed.

I have written several blogs on gallbladder polyps and have advocated against unnecessary operation, particularly for seafarers.

Gallbladder Polyps – Concerns of Seafarers and Others

Seafarer medical clinics which do not require operation for gallbladder polyps

Usual Clearance for Seafarers with Gallbladder Cholesterolosis

https://www.facebook.com/groups/1327847933955719/

Mission: Promoting the Health of Filipino Seafarers!



 

In an effort to reinforce my advocacy on no need for operation for gallbladder polyps, I searched again the literature today and I found this very important article.

http://pubs.rsna.org/doi/full/10.1148/radiol.10100273

Incidentally Detected Gallbladder Polyps: Is Follow-up Necessary?—Long-term Clinical and US Analysis of 346 Patients

Published in 2010

The management of GB polyps is currently influenced by concern for the presence or development of GB carcinoma.

In conclusion, we found no cases of GB malignancy in 346 patients.

Advances in Knowledge

•. The risk of gallbladder (GB) malignancy resulting from incidentally detected polyps is extremely low.
•. The risk of neoplasia in incidentally detected polyps is also extremely low, with none seen at diameters smaller than 7 mm.
Implication for Patient Care

•. Incidentally detected GB polyps measuring 6 mm or less require no additional follow-up.

Ergo, NO NEED FOR OPERATION (REMOVAL OF THE GALLBLADDER) FOR GALLBLADDER POLYPS – small ones and in asymptomatic patients

ROJ@17may18

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Skin and Soft Tissue Infections: Classification and Severity

Skin and soft tissue infections can be classified into purulent and nonpurulent ones.

Non-purulent ones are those without associated pus.  Purulent ones are those associated with pus.

Picture of non-purulent skin and soft tissue infections:

Cellulitis 

IMG_3576

Picture of purulent skin and soft tissue infections:

IMG_3822


Skin and soft tissue infections can be categorized in terms of severity as uncomplicated, complicated but non-necrotizing complicated, and necrotizing fasciitis.

Uncomplicated SSTIs

Uncomplicated SSTIs include superficial cellulitis, folliculitis, furunculosis, simple abscesses, and minor wound infections. These infections respond well to either source control management (ie, drainage or debridement) or a simple course of antibiotics. These infections pose little risk to life and limb.

IMG_4999

Complicated SSTIs

Complicated SSTIs involve the invasion of deeper tissues and typically require significant surgical intervention. The response to therapy is often complicated by underlying disease states. Complicated SSTIs include complicated abscesses, infected burn wounds, infected ulcers, infections in diabetics, and deep-space wound infections. They are often limb- or life-threatening.

viber image

Necrotizing Fasciitis

Necrotizing fasciitis is a progressive, rapidly spreading, inflammatory infection that is located in the deep fascia and is associated with secondary necrosis of the subcutaneous tissues. The inflammation of the deep fascia causes thrombosis of the dermal vessels, and it is this thrombosis that is responsible for the secondary necrosis of the overlying subcutaneous tissue and skin.

iii

The above classification and severity categorization are helpful as guides in management.

References:

http://emedicine.medscape.com/article/1830144-overview

Infectious Disease Society of America

ROJ@17may17

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Not all lesions on the breast are breast diseases

There are a lot of medical conditions involving the breasts.  These can be generally categorized into primary breast diseases (such as breast cancer, fibroadenoma and breast abscess) or not primary breast diseases (such as mole and cancer on the skin of the breast and epidermal cysts).

Here are some examples of the lesions not primary breast diseases:

Infected epidermal cyst.

Infected epidermal cyst on the breast.

Scald burns on the skin of the breast

ROJ@17may11

 

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Medical Decision Making and Informed Consent – Breast

Below is an illustration of medical decision-making and informed consent on a breast medical condition.

A 45-year-old female who had a history of macrocysts of the breast and which had been aspirated twice came for a check-up.

On examination, there was a questionable dominant mass on the left breast, about one-centimeter prominence.

A differential diagnosis of fibrocystic change (primary diagnosis) and macrocyst (secondary diagnosis) was given and explained to the patient.

Options given to the patient and advantages and disadvantages explained:

  1. Watch and wait – long wait of one month (for re-examination) – advantage: prominence may disappear.
  2. Ultrasound of the breast – early information can be gotten, whether fibrocystic change or macrocyst – if macrocyst, treatment options could be needle aspiration or just watch and wait (observe) – if fibrocystic change, just monitor (no procedure needed).

Patient decided to have an ultrasound done.  Note her signature below the ultrasound option signifying her decision.  This is an illustration of an informed consent.

Other patient may choose the watch and wait option, in which case, she will sign on the watch and wait option.

 

medical_decision_making_roj_17may6

ROJ@17may11



Follow-up – 17may18

Ultrasound of the breast was done which showed multiple cysts.  The prominence that was noted at about 1 o’clock position on the left breast showed a 2.1 cm cyst on ultrasound.  Since the cyst was not discrete on palpation and since it is just a macrocyst, shared decision was just to observe, watch and wait, and follow-up in 3 months.

us_breast

ROJ@17may18

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CT Scan Price List – Mediscan – 2017

ct_scan_mediscan_price_list_2017

ROJ@17may6

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Breast Cancer Survivor Carol Valenzuela – 14 Years in Remission

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Interplay of Mindsets of Physicians and Patients in Medical Decision Making

The decision-making on what a patient should receive in terms of medical management especially if he is awake and of sound mind is a result of integration and balancing of the mind-set of the physician and that of the patient (or the relative).

The mind-set of the physician and the patient consists of their philosophy, values, beliefs and perception on diseases, their causes and how they should be managed and treated.  They may differ and will have to be reconciled.  If the same and the patient puts his complete trust in the physician, then there is no problem in decision-making on what to do.

For example, a physician believes in mainstream medicine whereas a patient believes in faith healing or non-mainstream medicine such as folk medicine and alternative medicine. There must be reconciliation of the mindsets of both parties before a shared decision-making can be arrived at.

Another example, the patient believes his disease is caused by evil spirits but the physician believes otherwise.   Again, there must be reconciliation of these differing perceptions otherwise treatment of the patient will be difficult.

Another example, a physician may be a maximalist and a patient, a minimalist or vice versa.  A physician may be a believer of medical treatment and a patient, a doubter or vice versa.  A physician may look for the latest technology and a patient may look for natural healing or vice versa.  A physician may look for the most sophisticated technology and a patient may look for the simplest technology or vice versa.  All these different mindsets between a physician and a patient must be reconciled to come out with a shared decision-making.

The minimalists like to do the least possible for medical problems and the maximalist wants to be ahead of the curve and do anything and more.

Believers are people who believe there must be a good solution for their medical problems someplace, and they just have to find it. Doubters are very focused on side effects and on unintended consequences. They are concerned that the treatment might be worse than the problem.

http://healthland.time.com/2011/10/28/mind-reading-two-harvard-docs-talk-about-making-the-best-medical-choices

A personal approach in the practice of medicine in terms of proper physician mindset vis-a-vis patient mindset

As a physician, I have a certain mindset in the practice of my medical profession.

My mind-set can consist of the following:

As to type of medical treatment:

For faith-healing:
All patients with a remediable medical condition should do self-treatment or seek assistance from physicians or medical practitioners rather than just purely rely on prayer and an exercise of faith.  They can complement the self-treatment and treatment by physicians or medical practitioners with prayers and exercise of faith though (praying and hoping that they will be successfully healed).
For the non-faith healing medical practices:
All patients should give priority to mainstream medicine over non-mainstream medicine particularly those with data showing effectiveness for the former.  If there are data showing effectiveness for the non-mainstream medicine, go ahead.
The non-mainstream medicine may be use as a complement to mainstream medicine as long as they can be shown to produce better results when combined.

Minimalist vs Maximalist (I am more of a minimalist.)

Believer vs Doubter (I am more of a believer.)

Sophisticated vs Simple Technology (I am more for simple technology.)

Acceptance of reality that medicine is an inexact science – cannot guarantee cure – “Cure sometimes, relieve often, care always.”

I use this patient management process in problem-solving and decision-making:

steps_mgt_pt

My problem-solving and decision-making in the management of a patient is usually influenced by my mind-set.

I consider the mind-set of the patients to come out with a shared decision-making.  I respect the philosophy, values, beliefs and perceptions of patients but I can try to change them when I firmly believe it is necessary for a good medical outcome.  I will do so with cautious and respectful explanations.

ROJ@17apr28

 

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