A paradigm shift from operative to non-operative management of breast abscesses has occurred in surgical centres worldwide. The recent experience in managing these patients at the University Hospital of the West Indies (UHWI) was examined. Data were obtained retrospectively from dockets retrieved from the UHWI medical records department, and were analysed using the SPSS version 11.0 software package for Windows. Seventy-seven patients with breast abscesses presented during the 66-month study period, but complete data were unavailable for seventeen cases. The mean age of the remaining sixty patients was 32 years. There was one male patient. There were no cases of bilateral disease, and the majority was right-sided. Mean white blood cell count at presentation was mildly elevated at 11.9 x 10 9 /L, and had no relationship to method of management or length of stay. There were two cases treated with aspiration and antibiotics only. All other cases were treated with incision and drainage. Culture results were available in forty-four cases, and in 80%, Staphylococcus aureus was identified, with one case of methicillin resistant Staphylococcus aureus. The mean delay to the operating theatre was one day after presentation and the mean length of stay was 4.5 days. Seventeen patients had a 'non-cosmetic' incision. The traditional management of breast abscess provides challenges in terms of delay to the operating theatre and prolonged hospital stays. There is increased expense, as well as loss of productive work hours, associated with this line of treatment. Non-operative management has not traditionally been undertaken in our institution, but it is documented elsewhere to be safe, practical, and results in improved cosmetic outcomes. Prospective protocol-based trials are necessary to identify the patients most suitable for this line of management in a setting with limited resources.
We read with great interest the article by Williamson et al regarding their experience with hepatobiliary cystadenomas. We have noted that two of their three patients were under the age of 40 years. Although the definition of middle age is quite variable, most agree it matches the 40-60 age group. In our case report, the patient was a 16-yearold female 1 and we would therefore like the authors' opinion on whether this demographic description should be extended downwards. In addition, suspicious cystic lesions are typically associated with mural nodules, a finding that also characterises the premalignant mucinous cystadenoma of the pancreas.2 The magnetic resonance imaging in our patient did reveal a mural nodule and we wondered whether this radiological finding was sought in the patients of Williamson et al and whether this feature would increase the urgency of resection. Finally, frozen section was employed in our case, which not only confirmed the radiological finding of a biliary cystadenoma but ensured the resection margin was microscopically clear. Our opinion is that irrespective of whether malignant transformation has occurred, intraoperative assessment is critical to ensure that the margins are clear of tumour. We therefore recommend routine intraoperative ultrasonography, as suggested by others. We thank Maharaj et al for their comments regarding our short series on hepatobiliary cystadenomas. With regard to patient demographics, most of the cases reported in the literature suggest a middle aged predominance 1 but both the age of our youngest patient (25 years) and that in the report by Ravi et al (16 years) 2 fall outside this definition. These lesions are rare and the majority (80-90%) are detected within this age bracket but given that hormonal activity is implicated in their development, a diagnosis of cystadenoma should be considered in any postmenarcheal woman with a hepatic cyst.Accurate radiological assessment is vital to ensure the correct operative management is achieved; a hepatopancreatobiliary multidisciplinary opinion should be requested for any atypical hepatic lesions. Suggestive radiological findings for cystadenomas include mural thickening, internal septation in the cysts and the presence of mucin or blood in the cyst; each of our cases had one of these characteristic findings.3 It is our opinion that if one of these features is present or if any other concerning features are noted (for example, the presence of a solid component) in a hepatic cyst, then patients should undergo either urgent further investigation (which may include tissue biopsy) in cases of diagnostic uncertainty or formal resection of a potentially neoplastic lesion. We agree with Maharaj et al that intraoperative assessment of these lesions should be undertaken, and both frozen section and ultrasonography can facilitate this. Our unit routinely employs ultrasonography for hepatopancreatobiliary lesions to confirm preoperative radiological findings and to ensure adequate resection margins. The ultrasonography finding...
(mean BMI 26.0 in 2000e2001, 27.8 in 2010. Obese patients were younger compared to normal BMI patients (mean age 60.1 and 64.4 respectively, p¼0.003). The incidence of Barrett's oesophagus and reflux disease were not significantly different between groups. Operating time was significantly longer for obese patients (p¼0.018). R0 resections were similar between groups (normal patients 96.4% and obese 95.5%). The mean number of LNs resected (33 for both normal BMI and obese groups) and the LN ratio did not differ significantly between groups. Obese patients had significantly lower disease stages (32.3% stage 1 obese patients vs 16.2% stage 1 normal BMI patients, p¼0.006). Overall survival was longer for obese patients compared with those of normal BMI (81 months vs 55 months, p¼0.004). When matched for stage, this difference did not reach significance (p¼0.236). Disease free survival did not differ between groups. The overall complication rate was similar between groups (70.1% for normal BMI, 66.3% for obese). Conclusion This is the first study to evaluate BMI in a homogenous group of patients with adenocarcinoma undergoing subtotal oesophagectomy with a standardised radical lymphadenectomy. BMI and obesity among these patients increased with time. The radicality of surgery, in terms of LN yields and R0 resections, did not reduce in the obesity group and this is further supported by equivalent stage-matched long-term survival.
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