Breast abscess as the initial presentation of squamous cell carcinoma of the breast.

Breast abscesses are common and rarely harbour an underlying malignancy. Antibiotics and drainage by aspiration are the mainstays of treatment. We encountered two post-menopausal patients aged 48 and 70 who presented with acute breast abscesses that had an underlying squamous cell carcinoma of the breast. Infective aetiology was considered in each case and pre-operative diagnosis is possible but requires a high level of suspicion to avoid a delay in diagnosis. Aspirate from the abscess should be sent for both culture and cytology and if drainage is done, then biopsy of the abscess cavity is essential. Clinicians should be aware of the association of this rare primary neoplasm of the breast.

Severe gastrointestinal bleeding resulting in total gastrectomy in a patient with major burns--a case report.

Gastrointestinal hemorrhage is a known but rare complication of major burns. This case report describes the management of this potentially life threatening problem in a young adult with 45% body surface area burns who developed massive gastrointestinal-tract bleeding. The patient required a total gastrectomy that was complicated by a burst abdomen. Despite undergoing a series of major insults. the patient survived and was eventually discharged from hospital with an acceptable level of morbidity. The problems faced by the burn centre team and the issues involved in the decision making process are discussed in the management of this unusually devastating complication.

Experience with laparoscopic cholecystectomy at the Toa Payoh Hospital.

A retrospective analysis was done of 88 cases of laparoscopic cholecystectomy performed by the first author from November 1990 to March 1992 at the Toa Payoh Hospital. There were 61 female and 27 male patients; the average age was 47.1 years. The most common presenting symptom was biliary colic (85.3%), followed by acute cholecystitis (10.2%) and gallstone pancreatitis (4.5%). In the vast majority of patients, the diagnosis was established by ultrasound (96.6%) while the remainder was diagnosed by oral cholecystography (3.4%). The operation was performed using the usual 4 puncture approach with the single-handed technique of dissection. Antibiotic prophylaxis with a broad-spectrum agent was used in all patients and there was no incidence of wound infection. A low complication rate of 4.5% was experienced--consisting of 1 case each of subcutaneous emphysema, abdominal colic, fever and bile duct injury. There was no mortality in our series. The conversion rate was 9.1% and this was due to our policy of performing laparotomy whenever the safety of laparoscopic surgery was in doubt. The mean duration of postoperative hospitalisation was 3 days and 7 days after laparoscopic and converted cholecystectomies respectively. The majority of patients (61.4%) returned to work after 2 weeks.

Chronic haemodialysis with PTFE arterio-venous grafts.

BACKGROUND/AIM OF STUDY: End-stage renal failure (ESRF) patients requiring long-term haemodialysis need a durable vascular access. The arterio-venous fistula (AVF) with its long patency rate and low complication profile is usually the first choice procedure for vascular access creation. However when superficial veins are not suitable for AVF creation or have all been exhausted as a result of repeated AVF procedures, arterio-venous grafts (AVG) using polytetraflouroethylene (PTFE) to bridge arteries and veins is an alternative for provision of continued vascular access for haemodialysis. This study is a review of our experience in using PTFE AVGs for vascular access in patients requiring chronic haemodialysis. METHODS AND MATERIALS: A retrospective review was done on 92 grafts in 77 patients placed by 3 vascular access surgeons at the Singapore General Hospital from January 1989 to December 1994. RESULTS: There were 58 female and 19 male patients with a median age of 43 years (range 15-76 years). Twelve patients (16%) were diabetic and 6 patients (8%) had systemic lupus erythematosis requiring long-term steroids. Seventy-three percent of patients had up to 2 previous AVF creations before placement of AVG over the forearm (64%), upper arm (23%) or thigh (6.5%). Complications include graft infection (19), pseudoaneurysm formation (10), graft thrombosis (24), steal syndrome (1), venous congestion (1) and venous end stenosis (1). Diabetic status and long-term steroid therapy did not significantly increase the incidence of graft infection. The patency rates at 24 months and 36 months were 77% and 58% respectively. However serviceability rates were 61% at 2 years and 38% at 3 years mainly due to infective complications. CONCLUSION: PTFE AVGs offer reasonable patency and serviceability rates as a vascular access modality but in view of their complication profile, the native vein arteriovenous fistula should continue to be the first choice procedure for vascular access in patients requiring chronic haemodialysis.

A comparison of trucut biopsy with fine needle aspiration cytology in the diagnosis of breast cancer.

INTRODUCTION: Carcinoma of the breast is common in Singapore and many patients may present with just a suspicious breast lump. AIM: To determine the accuracy of fine needle aspiration cytology (FNAC) and trucut biopsy in the diagnosis of suspicious breast lumps in an outpatient setting. METHODS: A total of 39 women, from May 1995 to November 1995, who had a suspicious breast lump were subjected to concurrent FNAC and trucut biopsy. RESULTS: The accuracy of FNAC is 90% whereas trucut biopsy is 67%, the difference being statistically significant with a p < 0.02. CONCLUSION: FNAC is recommended for the diagnosis of suspicious breast lumps.

Acute embolic occlusion of the superior mesenteric artery: a case report and discussion of management.

INTRODUCTION: We present a case of acute embolus to the superior mesenteric artery (SMA). CLINICAL PICTURE: A 70-year-old gentleman with atrial fibrillation complained of colicky abdominal pain with clinical signs of tenderness and mild guarding. TREATMENT AND OUTCOME: Laparotomy revealed extensive bowel ischaemia but no overt infarction. The SMA was occluded by an embolus at the root of the mesentery and balloon catheter embolectomy was carried out at once. Bowel resection was deferred in order to allow clear demarcation of gangrene to avoid sacrificing unnecessary length. At second look laparotomy, 1.2 m of bowel from mid-jejunum to mid-ileum was resected, salvaging about 1 m of previously dusky small and large bowel. CONCLUSION: This case illustrates the importance of accurate history taking, the role of early intervention and the usefulness of a second look laparotomy in cases of mesenteric ischaemia to minimise the extent of bowel resection.

Endovenous laser treatment for varicose veins in Singapore: a single centre experience of 169 patients over two years.

INTRODUCTION: Endovenous laser therapy (EVLT) is one of the many minimally-invasive procedures that have been developed in recent years for the treatment of varicose veins. We present our single centre experience of 169 patients who underwent EVLT. METHODS: All patients who underwent EVLT since its introduction in our institution were included in our series. RESULTS: A total of 270 incompetent long saphenous veins in 169 patients were ablated by EVLT from February 2006 to January 2008. Bilateral EVLT was performed in 101 (59.8 percent) patients, with the remaining 68 (40.2 percent) undergoing unilateral EVLT. The mean age of the patients was 54 (range 19-78) years and there were 112 (66.3 percent) women. The majority of our patients (63.3 percent) had symptoms for more than five years. The symptoms included lower limb cramps and aches (47.9 percent) as well as lower limb swelling (16.6 percent). The median follow-up was six months. Complications from our series included numbness over the affected lower limbs (10.7 percent) and skin pigmentation (4.1 percent). Only 2.4 percent of patients had recurrence after one year. CONCLUSION: Early results with EVLT have been impressive, and this study has reaffirmed the safety and effectiveness of EVLT in the treatment of varicose veins.

Endovascular aortic repair: the experience of two tertiary institutions in Singapore.

INTRODUCTION: Endovascular aortic repair (EVAR) has gained prominence as a means of treating aortic disease, with lower perioperative morbidity and mortality compared to open surgery. This article aimed to describe the experience of two tertiary hospitals in a Southeast Asian population. METHODS: A retrospective review of 100 consecutive patients undergoing EVAR in two hospitals in Singapore was conducted. This included patients undergoing elective as well as emergency repair. RESULTS: The mean duration of follow-up was 31.8 months. The mean aneurysm size was 6.3 cm and the mean length of stay was 12.1 days. 64 percent of the patients were of American Society of Anesthesiologists class III or above. The deployment success was 98 percent. Major complications (acute myocardial infarction, pneumonia, cerebrovascular accidents, renal failure, colonic infarction and spinal cord infarction) occurred in 18 patients. Perioperative mortality occurred in six percent of cases. The endoleak rate was 28 percent. Both patients with colonic infarction had a single patent internal iliac artery post-procedure, and end-stage renal failure. CONCLUSION: Our results are comparable to published experiences in aortic stenting. Our population possibly had a higher incidence of short common iliac arteries. Revascularisation of internal iliac arteries should be considered for patients with end-stage renal failure and a single patent internal iliac artery.

Traumatic abdominal wall herniation.

Most reported cases of traumatic abdominal wall herniation result from seatbelt or handlebar injuries. The diagnosis is often made on physical examination or abdominal computed tomography (CT). We report a 59-year-old man with traumatic herniation through the rectus muscle following low-velocity blunt abdominal trauma. This patient was initially thought to have a rectus sheath haematoma and initial CT showed a soft tissue haematoma over the left lower anterior abdominal wall but no herniation. The traumatic herniation was diagnosed four days later, and confirmed on CT. Intraoperatively, a segment of the sigmoid colon was found to have herniated through the rectus defect and was gangrenous with impending perforation. A left hemicolectomy followed by primary repair of the defect was done. This case highlights the need for a high index of suspicion for traumatic herniation in patients who sustain low-velocity blunt abdominal wall trauma even when initial CT scans are negative.

Use of a peripherally implanted subcutaneous permanent central venous access device for chemotherapy--the Singapore General Hospital experience.

BACKGROUND: Venous access for chemotherapy patients at the Singapore General Hospital has conventionally been via an externalised (Hickman) catheter. A peripherally implanted permanent subcutaneous central venous access device (P.A.S.Port) was introduced in 1996. AIMS: We review its use, complications and cost competitiveness with other chemotherapy delivery systems. METHODS: A retrospective study of clinical records was conducted with follow up interviews of patients and nursing staff. RESULTS: Twelve patients had the P.A.S.Port inserted for administration of chemotherapy as an outpatient procedure. Immediate complications were pain (8%) and bruising (8%). One port-related infection (8%) one week following insertion was reported and one patient complained of interference with elbow movement as a late complication. Cost analysis was favourable for P.A.S.Port over an externalised Hickman catheter or chest-placed port at one year. Patient and nursing staff acceptance was high. CONCLUSION: P.A.S.Port insertion is a safe outpatient procedure and is an alternative for permanent venous access.