Pedunculated or Sessile Polyp?

I was in the second year of my graduate course studying pathology. It was then that I learned that all tumors that grew from any surface either had a stalk or pedicle, or did not have one. Those with pedicles were called pedunculated and those without were called sessile. A little later I studied Gynecology. I learned that leiomyomas arising from the outer or inner surface of the uterus could be pedunculated or sessile. A pedunculated mass arising from a mucosal surface was also known as a polyp. This information has an important bearing on the management of the tumor. A benign pedunculated tumor can be removed easily by dividing its pedicle. A sessile tumor cannot be removed so easily, and has to be dissected out of its bed. All this information is quite basic, and is required to be known by the graduate and definitely the postgraduate students.
We were in a clinicopathologic meeting, attended by our doctors as well as pathologists. One case was being discussed, who had a polyp of the uterus.
"Polyps can be pedunculated or sessile" a Professor from the other department said.
There was a deadly silence among both gynecologists and pathologists, at least those who were paying attention or not dozing. No one said anything for quite some time. Then the resident doctor who was presenting the case started where he had been interrupted. The meeting moved on.
"Has she/he* gone bonkers?" someone said after the meeting. "How can she/he make such a statement?"
"She/he is known to make such statements. That is how God has made her/him" a knowledgeable person said.
"But what about the students taught by her/him? They will remember that and get in trouble in exams" a third person said.
"They don't pay attention to the teachers. They read books for their education" a fourth person said.
"I hope she/he has not written a book and if she/he hasn't, is not planning to write one" a fifth person said.
"I think she/he was not concentrating, and said polyp in place of a leiomyoma" I said. That sounded correct. It also fitted in the behavior of the person concerned.
(* She/he is used to protect the identity of the person concerned).

Dig Deeper

"Sir, we have received the histopathology report of Mrs. XXXX" my Registrar said.
"What about it??" I asked. We got such reports of all our operative cases. There had to be something unusual about it for her to say so.
"It says 'material inadequate. Do a deeper curettage'".
I remembered that patient. The material had been scanty when we had done a dilatation and curettage. But that had not been due to any lack of effort.
"I remember. The operating surgeon had done a really good curettage, despite which  there was hardly any material" I said.
"So what shall we do?" the Registrar asked.
"The endometrium was atrophic. So there was no material. We cannot get any material if we repeat the curettage and curette deeper as the pathologist has suggested. We have to treat her condition appropriately, based on her symptoms. Let her see me when she comes to the outpatient clinic the next time."
The Registrar went away. This was the second time someone had erroneously told us to dig deeper into the endometrium. This time it had been an Assistant Professor of Pathology, while I was Professor and Head of my department. The first time it was the Assistant Professor of my department while I was a first year resident doctor 34 years ago. That patient was young. She had abnormal uterine bleeding.
"Admit her and do her endometrial curettage" the Assistant Professor told me.
I did that. The patient came for a follow up. Her histopathology report was 'proliferative endometrium'. She was still bleeding. Instead of treating her with appropriate medicine, like a progestin, the Assistant Professor said, "you have not done a good job. Admit her and do her endometrial curettage again."
I knew I had done a good job the first time. But there was military discipline in the civic hospital. So I followed orders and repeated the curettage. The report was still the same, and the patient continued to bleed.
"Can't you do a good curettage? I am telling you, do a GOOD curettage" the Assistant Professor said.
So I admitted the poor woman and did a good curettage a third time. The third report was ' endometrium in prolifeative phase. Bits of myometrium seen.' When the Assistant Professor saw that report, she said, "I think you have done a good job. Though she is still bleeding, don't do a curettage again. She cannot afford to lose myometrium. We will treat her medically." I don't know what treatment she gave to that patient. But I do know that she did not teach me the right management of such a patient, probably because she did not know it herself. I had to learn it from her mistake, and by reading books on my own.

Reverse Trend in Hysterectomy for Cervical Cancer

For those who don't know, hysterectomy means surgical removal of the uterus. When the body of the uterus is removed and the lower part called cervix is left behind, it is called as subtotal hysterectomy. In general it is recommended that the cervix be not left behind, because a cancer may develop in it at a later date, and then the treatment of that cancer becomes difficult. Only in difficult situations does one leave he cervix behind, such as when the urinary bladder or rectum is densely adherent to the cervix.
That woman came from a place in north India. Some surgeon had removed her uterus.
"Why was a hysterectomy done on you?" I asked her.
"The doctor said it was the beginning of a cancer in the cervix of my uterus" she said, and showed me her case paper. "But he did not remove the cervix." I checked her papers. A subtotal hysterectomy had indeed been done for cervical intraepithelial cancer.
"But if it was done for the beginning of a cancer of the cervix, the cervix had to be removed" I said with amazement.
"Yes, doctor" she said tearfully, "but he did not remove it. It seems they do hysterectomy like this on all patients there."
I checked the doctor's prescription. His degree was MS in general surgery. I could not understand why a general surgeon would perform a hysterectomy these days. It was the job of a gynecologist.
"Doctor, save me" she said. "I have two small children."
"Don't worry" I said. "We will remove that cervix. It does not look like it is cancerous." It wasn't. I performed a vaginal removal of the cervix. It was a little difficult, because the abdominal structures were stuck to its top, and they had to be protected during its removal. Later on when I related this story to a friend, he said,
"If a young woman has cervical cancer and she desires to have more babies, they perform a radical removal of the cervix and keep the body of the uterus behind. This seems to be exactly opposite. The surgeon removed the body and left behind the cervix which he believed to have a cancer."
"Yes. This is a reverse trend in hysterectomy for cervical cancer. I hope he does not get any more patients like this."

Abdominal Distension - Different Approaches

I don't know which of the following three stories told in a story telling competition that was held during my residency is the best.

Story 1
This one happened when I was doing my residency in Obstetrics and Gynecology many years ago.
There was a 23 year old woman with acute abdominal pain. The surgeons had decided she had a lump in the abdomen that was excruciatingly painful. She was admitted and put on the operation table. It was the middle of the night and they were waiting for an anesthetist. She was screaming with pain so much, that they left her in the operation room and sat at the table outside. Suddenly her screams stopped.
"Go see if she has died or something" the Registrar said.
The houseman went in to check and came out on the double.
"She ...ah..."
"What?" the Registrar asked, suddenly worried.
"She is OK. The painful abdominal lump is gone, and there is a baby between her legs. I don't know what to do about the umbilical cord that seems to be going inside her."
The woman was spared a laparotomy by a busy  or tardy anesthetist. The surgeons had not realized she was pregnant and in labor.

Story 2
The woman was 8 months pregnant. She had a valvular heart disease and was in early cardiac failure. We sent a call to the cardiologists. The cardiology Registrar saw her and advised some cardiological tests. He also advised an ultrasonography of the abdomen.
"A cardiologist wants an ultrasonography of the abdomen?" I asked, surprised. "This is the first time I have seen this happen. Please ask him why he wants one."
My Registrar asked and informed me about it.
"He wanted it to see if there was any large mass or fluid in the abdomen, that would compromise her breathing and cause breathlessness."
Of course she had both a large mass (the fetus) and fluid (amniotic fluid) in her abdomen, just like all pregnant women have.

Story 3
The woman was admitted in the medical ward with severe anemia. Her hemoglobin was 4 g/dL (normal range is 12.5 to 14 g/dL). We received a call from the medicine residents. My Registrar saw her and reported back to me.
"The patient is 35 weeks pregnant and has severe anemia."
"OK. What did they want from us?" I asked.
"Actually their professor asked them to do an ultrasonography and send us a call at the same time. The professor thought she had a uterine fibroid, which was causing the anemia."
"Fibroid causes heavy menstrual bleed loss, while a pregnancy causes amenorrhea (absence of menses)" I said. "You can actually feel the baby at such an advanced stage of pregnancy."
"The professor felt it was a fibroid" my Registrar said.
If we could diagnose a heart disease, anemia, pneumonia, and cirrhosis, the medicine guys should be able to diagnose an advanced pregnancy, I thought. Well, the 'should's may be very well justified, but that does not make them real.

P.S. (29-11-2014)
There was another patient who was single, admitted in the medical ward. She was there for investigations of hepatosplenomegaly. The got an ultrasonography done on her as a part of the diagnostic work up. It showed she was 8.5 months pregnant and had no hepatosplenomegaly. It goes to show that they do not read my blog, or read it just to get angry if there is anything that they think is criticism rather than praise. Well, I praise them for managing so many patients so well despite being understaffed. The purpose of writing such posts is not to criticize, but to try and avoid such happenings in future.

Superspecialty Focus

"Doctor, they have sent me to you from the cancer hospital" the patient said. I was surprised. Usually we sent them patients for management. This seemed to be an exception.
"What is the problem?" I asked.
"I have white discharge and pain in lower abdomen" she said. It looked like pelvic infection and vaginitis.
"Do you have itching of the private parts?" I asked. It may seem like a little too personal question. But it is essential with the symptom of white discharge, and no patient of ours has found it embarrassing.
"Yes" she said.
So it looked like I was right. I examined her and confirmed that she had both of those conditions. I gave her appropriate advise and prescribed her specific medicines to cure her conditions.
"Why did you go to the cancer hospital?" I asked her.
"I had this white discharge, and my local doctor said it could be cancer" She said.
"Show me the reports from the cancer hospital" I said. She did so. They had checked her Pap smear, done a test for Human Papilloma Virus, and performed a cervical biopsy. Thus they had ruled out cervical cancer and referred her to a gynecologist. They had spent a lot of money, specialist time (clinician and pathologist included) both of which were wholly unnecessary. All of their and the patient's troubles would have been avoided if she had gone to a gynecologist primarily.
When I narrated this story to a friend, he asked "why did this happen?"
"That happened because a superspecialist is very focused on his work, and cannot see beyond. Then he misses out a lot of things that a specialist or even a family physician would pick up more easily."

DIC Dilemma

"Sir, this patient came to us with placental abruption early morning" the Registrar informed me during the round of the labor ward. "She had DIC. She delivered two hours ago."
"So what did you do?" I asked. DIC is short for disseminated intravascular coagulation. It is a serious condition in which the patient's blood does not clot and she bleeds profusely, sometimes to death unless treated in time.
"We are going to transfuse her with six units of fresh frozen plasma."
"You are going to? You mean she delivered without correction of her DIC?" I asked.
"Yes, Sir. There was some problem with getting fresh frozen plasma. But now we will get it."
"But she did not bleed after delivery?" I asked.
"No, Sir. The uterus is well contracted and retracted. There is no bleeding at all."
"If she has not bled for two hours after delivery, she is not going to bleed now. Her body will correct whatever coagulopathy she has got, if any. She does not require and treatment" I said. "The diagnosis was probably wrong. She did not have any DIC."
"Sir, her PT-INR was 1.72, and plasma fibrinogen was 56 mg%."
"That sounds terrible. But believe me, she is OK. Where did you get the tests done?"
"In the private lab outside the hospital, except PT-INR which was done in the hospital's emergency lab" the Registrar said.
"Sir, I think we should treat her" the Associate Professor said. "She could bleed later."
"But the uterine vessels must have thrombosed by now. How will she bleed?" I asked.
"Suppose she does?"
"Yes, medicolegally that could pose a problem" I agreed. "Treat her."
At that time I saw doctors of another unit in the labor ward, taking round of their patients. I had an idea. I stopped their chief and said, "Can I ask you an academic question?"
"Yes."
So I explained the situation and asked, "Will you give such a patient fresh frozen plasma even if she has not bled for 2 hours after delivery?"
"Yes. She could bleed elsewhere, say in the brain?"
"Hmm...." I said.
"What are you going to do?"
"We will treat her because we do not medicolegal claim of negligence. But if I were that patient, I would not take this treatment myself." I said.
Our Registrar had send that patient's DIC tests again that morning, before starting treatment, but after she had delivered and not bled. These tests were sent to our routine lab in the hospital.
"I want to see the results of those tests" I told the Registrar" I said, "because I am sure there is an error in the diagnosis."
I was shown the results the next day and they were as shown below.

Parameter	Before delivery, before treatment	After delivery, before treatment
Plasma Fibrinogen	56 mg%	220 mg%
PT-INR	1.72	0.98
D-dimer	More than 10	0 – 5
aPTT	44/28 (Patient/control)	30.5/28.5 (Patient/control)

"The reports after delivery are normal, which cannot happen in two hours. She had no DIC" I said. "The private lab has given you wrong reports, and you believed them, rather than the clinical evidence that she had no bleeding problem. I hope you learn to believe what you find in a patient clinically rather than what some laboratory says."

Vaginal Myomectomy - 2

I had done a myomectomy by this technique long ago. It had been just 1.5 cm diameter leiomyoma that had arisen from the anterior lip of the cervix. It had no pedicle. I had cut its surface, enucleated it, and reconstructed the cervix. This time it was about 6 cm in diameter. It had arisen from the lower 1 cm of the anterior wall of the cervical canal. The cervix was 5-6 cm dilated, 50-60% effaced, and had only right, left and posterior lips. The anterior lip had been taken up by the leiomyoma. There was a broad base attached to the cervix, and no pedicle. Conventionally one would have cut it near the base and occluded the raw area with sutures. I decided to do otherwise. Normally one does not expect submucosal leiomyomas to have a pseudocapsule. I decided to see if that was true. So I cut its mucosal cover and underlying tissues with cutting electrocautery over 4-5 cm in midline. Then I dissected bluntly, and found that it did have a pseudocapule. I enucleated the entire leiomyoma from inside the pseudocapsule. The upper part of the cavity left behind was quite high. There was no active bleeding from it. I sprayed it with Feracrylum solution to ensure that any potential bleeder there would be stopped, placed a piece of oxidized cellulose in it as an additional safety measure, and then excised redundant part of the pseudocapsule and mucosa. Then I sutured the rest to the anterior wall of the cerical canal with polyglactin sutures, occluding the cavity in that process. The leiomyoma had expanded the cervical canal circumferentially, and the internal os was far away from the suture line.
The experience was very satisfying, and so was the result. I think this method is a better alternative to conventional method of treating such leiomyomas.

Free Open Access Journal

Those who do not want to read the background, but want to visit the journal directly, here is the link to the journal.
Journal of Postgraduate Gynecology & Obstetrics 
I have toyed with the idea of publishing a journal of gynecology and obstetrics time and again. I always knew it would be a lot of work, but that did not matter much. There were a few journals which were free, and did publish articles we sent them. At those times, my enthusiasm for publishing a journal would wane. Unfortunately times changed. People started becoming editors of journals because it was prestigious. But they either did not recognize good material, or had nonacademic reasons to reject good material. I recall an article on a copper IUD that had become bare after retention in the uterus for years. It was sent by a colleague of mine to a 'prestigious' journal in the west against my advice. They returned it saying copper devices were not used any more. My colleague pointed out that copper devices were very much in use all over the world. Then the editor wrote back saying the article would not interest their readers.There was another 'prestigious' journal in town, where we had sent an article on an intramyometrial pregnancy, with a photograph. The editor returned it with the comment - 'the case seems fictitious'. I could not understand how anyone could produce a photograph showing a tunnel from the uterocervical canal going into the myometrium, with a pregnancy at the end of the tunnel. We published it in a national journal. Now the journals have turned fancy. They have online submissions, peer reviews, online or offline payments and publications. Unfortunately they understand that academicians are required to publish scientific articles. So they charge the sky. One such journal wanted me to publish my article in it. I asked the price, which turned out to be more than my salary for a month.All this and much more of it that I find too distasteful to write led me to start a journal of our own. It would disseminate useful experiences of doctors. It would also help the faculty and Resident doctors meet the requirements of the medical council and health university respectively.
Its title is 'Journal of Postgraduate Gynecology & Obstetrics'. It is open access, peer reviewed, and totally free. The first issue is scheduled to come out on first January 2014. Those who want to see what it will be like may see it at the following link. I invite all gynecologists and obstetricians to write for it.
Journal of Postgraduate Gynecology & Obstetrics

Wren and Martin & Doctors

English is taught as first or second language in schools. After the higher secondary school board examination, students lose all contact with English grammar and composition. It is a long way to medical graduation and even longer to postgraduation. A lot is forgotten in this time. As a result, the use of spoken and written English often leaves much to be desired. Read the following two sentences which I heard during a scientific meeting recently, the speaker being a doctor and Director in a Government research organization.

1. That was the very good.
2. They are a very important.

I am an editor of a journal of Gynecology and Obstetrics. I will write more about it some other time. I want to write on only one aspect of it here. I receive a lot of articles for publication in this journal. Some are in good English, others are not. The punctuation marks are just before the next word or sentence instead of at the end of the previous one. The verb is in plural form while the subject is in singular form. Articles are missing, or a definite article is used instead of an indefinite article. The list is endless. I even find SMS language in the text. This is a very discouraging experience. But it has a very great advantage. It helps me check for plagiarism.
"How?" someone asked me when I said this.
"It is simple" I said. "When the grammar, composition, spellings and punctuations are horrible, I am sure it is all original. When it is good English, it is very likely to be copied from some source and pasted."
"That is brilliant detecting" that someone said. "But doctors do that?"
"They are human beings and many human beings want an easy way out. It is so easy to find something on the net or in ebooks, which can be copied and pasted, to be passed as one's own work. It is much more comfortable and the results are so much more pleasing than thinking out text and typing it."
"But plagiarism is copyright violation. It is against the law."
"I wish they would believe me when I told them so" I said. "I had made one of my Resident doctors buy a copy of 'Wren and Martin' (a grammar book) to improve her/his English. The book remained in mint condition even after this Resident doctor qualified and went away."
"Huh?"
"Unfortunately, yes" I said.