The role of major duct excision and microdocectomy in the management of nipple discharge: Diagnostic and therapeutic approach

Mammary duct ectasia is considered as a benign condition of the mammary gland. Many theories analyses and summarized the disease regarding the pathogenesis. Firstly, the primary pathological process is due to be involutional and atrophy of the ducts. Other cause of dilation of the ducts, leading to the decrease or absent of secretion, inflammation and duct rupture. Secondly, the causative factor is inflammatory process with periductal inflammation followed by obliteration of ducts, sclerosis of duct and surrounding tissue and duct ectasia. Mostly mammary duct ectasia resolves without any treatment. Applying light warm compresses to nipple and wearing a supportive bra, can help to reduce discomfort of the patient. But If there is evidence of an infection, antibiotics will be prescribed without hesitation. It’s completely prohibited to squeeze the area to increase discharge, as there is increase chance to develop inflammation and infection. If symptoms still persisted than surgery may be done to disconnect the ducts and remove the ducts, Known as Hadfield’s operation. Recently sub-areolar major mammary duct excision – Hadfield’s procedure is very popular and has gained widespread acceptance in management of nipple-areola complex problems like suspicious or troublesome discharge, clinical or sono-mammographic central anomalies and chronic sinus-fistula. Here two cases with nipple discharge managed with two very common surgery with microdocectomy and total duct excision held in Z.H Sikder Women’s Medical College Hospital. Patients were very satisfied with the treatment as they got relief of symptoms and most importantly get rid of the fear of carcinoma.

Modified Techniques Versus Hadfield’s Procedure in Patients With Periductal Mastitis

Background: Periductal mastitis (PM) is a rare disease characterized by chronic inflammation of the terminal mammary ducts. Complete removal of the terminal canals with Hadfield’s operation applied in the treatment carries various complication risks. This study is designed to evaluate the effectiveness of modified techniques and compare them with the Hadfield operation.Methods: Twenty women who underwent surgery due to PM between January 2012 and December 2019 were retrospectively analyzed. Types of PM were determined. All patients were operated on with three different incisions (Hadfield’s operation with periareolar incision, periareolar combined with radial incision, and round block incision). Results: The age mean 37.5±6.5 years (range:24-49). Sixty percent of patients had type three PM. For the affected duct excision, a classic Hadfield’s operation with periareolar incision was performed in 11 patients, periareolar incision combined with radial incision was performed in 7 patients. The round block method was performed on two patients. Seroma was observed in only one of the patients who underwent the modified technique. In Hadfield’s procedure, NAC retraction (n:2), seroma (n:1), and hematoma (n:1) were seen. The follow-up period was 12±1.5 months. Recurrence occurred in two patients, and both had Hadfield’s procedures. Conclusions: The main principle of surgical treatment is excision of the affected canal with a clear margin. In PM treatment, The round block method and periareolar incision combined radial incision modifications of the Hadfield procedure reduce complications and recurrence risk.

Magnetic resonance imaging in the evaluation of pathologic nipple discharge: indications and imaging findings

Pathologic nipple discharge (PND) is typically unilateral, spontaneous, involves a single duct, and is serous or bloody in appearance. In patients with PND, breast MRI can be helpful as an additional diagnostic tool when conventional imaging with mammogram and ultrasound are negative. MRI is able to detect the etiology of nipple discharge in 56–61% of cases when initial imaging with mammogram and ultrasound are negative. Advantages to using MRI in evaluation of PND include good visualization of the retroareolar breast and better evaluation of posterior lesions which may not be well evaluated on mammograms and galactograms. It is also less invasive compared to central duct excision. Papillomas and nipple adenomas are benign breast masses that can cause PND and are well visualized on MRI. Ductal ectasia, and infectious etiologies such as mastitis, abscess, and fistulas are additional benign causes of PND that are well evaluated with MRI. MRI is also excellent for evaluation of malignant causes of PND including Paget’s disease, ductal carcinoma in-situ and invasive carcinoma. MRI’s high negative predictive value of 87–98.2% is helpful in excluding malignant etiologies of PND.

Meta-analysis and cost-effectiveness of ductoscopy, duct excision surgery and MRI for the diagnosis and treatment of patients with pathological nipple discharge

Introduction Pathological nipple discharge (PND) is a common breast-related complaint for referral to a surgical breast clinic because of its association with breast cancer. The aim of this meta-analysis was to compare the diagnostic efficacy of magnetic resonance imaging (MRI) and ductoscopy in patients with PND. Additionally, we determined the most cost-efficient strategy for the treatment of PND and the detection of breast cancer in PND patient without radiological suspicion for malignancy. Materials and methods PubMed and EMBASE were searched to collect the relevant literature from the inception of both diagnostic methods until January 27th 2020. The search yielded 815 original citations, of which 10 studies with 894 patients were finally included for analysis. Costs of ductoscopy, MRI and duct excision surgery were obtained from the UMC Utrecht as established in the year 2019. These costs included: medical personnel, overhead costs, material costs and sterilisation costs. Results The meta-analysis showed no significant difference in sensitivity between ductoscopy (44%) and MRI (76%) for the detection of malignancy in patients with PND. However, ductoscopy (98%) had a statistically significantly higher specificity than MRI (84%). Individual costs were €1401.33, €822.13 and €6494.27 for ductoscopy, MRI and duct excision surgery, respectively. Full diagnostic strategy involving ductoscopy was on average €1670.97, while with MRI it was €2070.27. Conclusion Patients undergoing MRI are more often (false) positive which more often leads to duct excision surgery referrals compared to ductoscopy. This makes ductoscopy significantly more cost-effective compared MRI in patients with PND without radiological suspicion for malignancy.

Patient-reported outcomes of ductoscopy procedures for pathologic nipple discharge

Background Pathologic nipple discharge (PND) is a common complaint often associated with breast cancer. However, when ultrasound and mammography are negative, the chances of malignancy are lower than 5%. Currently, major duct excision and microdochectomy are often recommended to alleviate symptoms and definitely rule out malignancy, but can cause infections and breastfeeding problems. Ductoscopy is a minimally invasive endoscopy technique that allows visualization of the mammary ducts and may not only obviate surgery but also detect malignancy. The aim of this study was to determine quality of life (QOL) after ductoscopy in patients with PND. Materials and methods All PND patients referred for ductoscopy between 2014 and 2015 to our hospital were included. Ductoscopy procedures were performed under local anaesthesia in the outpatient clinic. Patients were asked to fill out questionnaires (Breast-Q, EQ-5D-5L and SF-36) on the day of ductoscopy, and after 2 weeks, 3 and 6 months. Additionally, we performed reliability analysis to determine if these questionnaires were suitable for PND patients. Results Fifty consecutive patients underwent ductoscopy of whom 47 patients participated in this study. One domain of SF-36 (vitality) varied significantly over time. Breast-Q, SF-36 and EQ-5D-5L showed that QOL after ductoscopy for PND was unaffected by ductoscopy. Success of the ductoscopy procedure was a significant predictor for satisfaction with the result domain. Conclusion Ductoscopy is a minimally invasive technique that does not seem to impact QoL of PND patients over time. Breast-Q, SF-36 and EQ-5D-5L seem to be suitable existing QOL tests for PND patients undergoing ductoscopy, whereas SF-36 would require modifications.

Foreign bodies of submandibular gland and Wharton’s duct: a review of literature

<p class="abstract">Foreign bodies of submandibular duct are rarely but consistently reported in literature. They usually present as obstructive submandibular sialadenitis. The diagnosis can be challenging because of rarity of such an event, and inability of traditional diagnostic methods to detect the foreign body. We sought to assemble the previous published literature to delineate the presentation, investigation and management of submandibular gland foreign bodies. We performed a comprehensive systematic literature review of PubMed, and Google Scholar, databases from 1960 to 2019, and analyzed the case reports and research articles proclaiming detection of foreign body in the submandibular gland or its duct. We also included a case found in our hospital in the review. A total of 28 articles full filled our criteria. The earliest article found was from year 1962 and latest in 2019, amounting to 28 research articles on this topic in last 58 years. The age ranged from 9 years to 78 years, with average age of 38.7 year. The left Submandibular gland was involved in 18 cases (75%), and right in 6 cases (25%). There was a varied array of foreign bodies retrieved. Patients underwent sialadenectomy, duct excision, intervention by milking, probing or with a forceps or more recently interventional sialendoscopy. To approach an early diagnosis, a patient history needs to be believed. High resolution oral ultrasonography with interventional sialendoscopy can become the hallmark of a future approach to submandibular duct foreign bodies.</p>

A rare case of eosinophilic cholangiopathy

Eosinophilic cholangiopathy is termed as a rare, benign, and self-limiting disease. Moreover, the interference of malignant tumor to diagnosis and the changing process of disease make the accurate treatment proposal challenging. A significant number of patients require surgery for the definitive diagnosis and resolution of symptoms. We put forward a case of eosinophilic cholangiopathy infiltrating the gallbladder and bile duct with bone marrow involved, coupled with peripheral eosinophilia. The patient underwent a successful treatment using laparoscopic cholecystectomy and steroids, instead of extrahepatic bile duct excision with Roux-en-Y hepaticojejunostomy. The patient gets an accurate treatment in a minimally invasive manner. In conclusion, surgery refers to not only a diagnostic methodology but also a treatment. When the bile duct and gallbladder are involved at the same time, and cannot distinguish benign and malignant diseases, laparoscopic cholecystectomy is feasible, the effect is the same, and the symptoms of eosinophilic cholecystitis are relieved.