Office Address

Dr. Pawan Lal, Professor of Surgery, R. No. 229, B. L. Taneja Block, MAMC campus, Delhi - 110002, India

Residential Address

Dr. Pawan Lal, C - 63, Preet Vihar, Vikas Marg, (Opp. Pillar no. 78), Delhi - 110092, India

Contact

M: +91 9968604405,                                                              Email: info@pawanlal.com

Dr. Pawan Lal

MBBS, MS, DNB (General Surgery),

MNAMS, FICS, FIAS, FIMSA, FIAGES,

Professor of Surgery

Maulana Azad Medical College

(Delhi University)

New Delhi, India

About Dr. Pawan Lal

Dr. Pawan Lal, did his Graduation from University College of Medical Sciences, Delhi, affiliated to University of Delhi. After his graduation he joined as post graduate student in Surgery in prestigious Maulana Azad Medical College, New Delhi, (affiliated to University of Delhi). He submitted his doctoral thesis titled " Prediction of difficult Laparoscopic Cholecystectomy and it's conversion to open cholecystectomy from the ultrasonography", under the expert guidance of Dir. Prof. and Head of Department, Dr. P. N. Agarwal. After finishing his post-graduation he joined as Registrar (Senior Resident) in the Department of Surgery, Maulana Azad Medical College, New Delhi. After completing his Registrarship in Surgery, he did his diploma in Anaesthesia from Department of Anaesthesia, Maulana Azad Medical College, New Delhi (Affiliated to University of Delhi). 

He joined as Assistant Professor of Surgery in Vardhaman Mahavir Medical College and associated Safdarjung Hospital, New Delhi. After completing one and half year in Vardhaman Mahavir Medical College and associated Safdarjung Hospital, he joined Prestigious Maulana Azad Medical College as Assistant Professor.

Dr. Pawan lal became Associate Professor of Surgery in year 2010 and Professor of Surgery in the year 2014

Breast Duct ectasia

Duct ectasia of the breast or mammary duct ectasia or plasma cell mastitis is a condition in which the lactiferous duct becomes blocked or clogged or in other words mammary duct ectasia occurs when a milk duct beneath the nipple widens, the duct walls thicken and the duct fills with fluid. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age. The lactiferous ducts (milk duct) may become blocked or clogged with a thick, sticky substance. The condition often causes no symptoms, but some women may have nipple discharge, breast tenderness or inflammation of the clogged duct (periductal mastitis).

Mammary duct ectasia most often occurs in women of perimenopausal age — around 45 to 55 years — but it can happen even earlier age and even after menopause, too. The condition sometimes improves without treatment.

The duct widening is commonly believed to be a result of secretory stasis, including stagnant colostrum, which also causes periductal inflammation and fibrosis.

Causes

  • Breast tissue changes due to aging. As the body ages, the composition of your breast tissue changes from mostly glandular to mostly fatty in a process called involution. These normal breast changes can sometimes lead to a blocked milk duct and the inflammation associated with mammary duct ectasia.
  • Smoking. Cigarette smoking may be associated with widening of milk ducts, which can lead to inflammation and could be responsible for mammary duct ectasia.
  • Nipple inversion. A newly inverted nipple may obstruct milk ducts, causing inflammation and infection. A nipple that's newly inverted could also be a sign of a more serious underlying condition, such as cancer.
  • Benign intraductal papilloma
  • In approximately 10% (4%-20%) of cases, DCIS or invasive disease may be found upon histological analysis of the specimen

Signs and symptoms:

  • A dirty white, greenish or black nipple discharge from one or both nipples
  • The discharge can sometimes be bloody
  • Tenderness in the nipple or surrounding breast tissue
  • Redness of the nipple and sometimes the surrounding area
  • Infection - periductal mastitis which if left untreated infection can lead to an abscess
  • A breast lump or thickening near the clogged duct
  • A nipple that's turned inward (inverted)
  • Concern about breast cancer - mammary duct ectasia does not increase your risk of breast cancer.
 
Mastitis also may develop in the affected milk duct, causing breast tenderness, inflammation in the area around the nipple (areola) and fever.
 
Signs and symptoms of mammary duct ectasia may improve on their own.
 

Investigations

  • Diagnostic ultrasound of the nipple and areola
  • Mammography.
  • MRI of breast

Treatment / Management

  • Antibiotics and Pain medication - for mastitis and peri-ductal inflammation if it occurs.
  • Surgery - the affected milk duct may be surgically removed

 

Microdochectomy - Excision of the single affected duct is called microdochectomy - it is done if the patient wishes to preserve breastfeeding ability, the condition of the mammary duct system is investigated by means of ductography or ductoscopy. The excision of a single duct affected duct is done through the circum-areolar incision (microdochectomy). Even when microdochectomy is performed the ability to breast feed in the future cannot be guaranteed as sometimes the scarring from surgery is suffiecient to obliterate the ducts. Procedure is done by cannulation of the discharging duct using a lacrimal probe or inject Methylene blue for duct identification, the duct is then identified through circum-areolar incision. 

 

Major Duct Excision (also called as Central Duct excision or Hadfield's procedure)

There are approximately 12-15 ducts in the breast which open onto the surface of the nipple. Where excision of a single duct is called microdochectomy, the more common procedure of Major duct excision (also known as total duct excision or Hadfield’s procedure) is the surgical removal of all lactiferous ducts under the nipple.

 

Indications of Hadfield's Procedure

Central duct excision is a standard treatment of in case there is nipple discharge which stems from multiple ducts or cannot be traced back to a single duct. It is also indicated if there is bloody nipple discharge in patients beyond childbearing age.

Duct excision may be indicated for the treatment of recurrent breast abscess and mastitis, and the total removal of all ducts from behind the nipple has been recommended to avoid further recurrence.

Pre-operatively, also breast ultrasound and mammogram are performed to rule out other abnormalities of the breast.

 

Procedure

The surgical approach is through an inferior periareolar incision or a circumareolar incision (following the circular line of the areola). The skin flap is raised behind the nipple preserving the blood supply to the nipple. Once the ducts are identified they are encircled using blunt dissection with an artery clip or scissors from both sides. The Ducts are disconnected the the tissue is coned down to 4 or 5 cm using diathermy. The defect behind the nipple is closed using Vicryl and if the nipple was inverted prior to surgery and everted during surgery then a figure of 8 suture at the base of the nipple will prevent it everting again. Local Anaesthetic without adrenaline is used and the wound is closed in 2 layers with Monocryl.

 

Complications

  • Nipple tip necrosis
  • Hemorrhage or bleeding
  • Altered sensation, shape, size and color of the nipple
  • Infection
  • Hematoma
  • Nipple inversion
  • Breastfeeding is no longer possible.

 

 

For patients

For evaluation of a new breast lump or changes in your breast, visit for investigations and clinical examination is a important.

What you can do

  • Take note of all your symptoms, even if they seem unrelated to the reason for which you scheduled the appointment.
  • Review key personal information, including major stresses or recent life changes.
  • Make a list of all medications, vitamins and supplements that you regularly take.
  • Write down questions to ask your doctor

For mammary duct ectasia, here are some questions you might ask your doctor:

  • What's causing my symptoms?
  • Will this condition resolve itself, or will I need treatment?
  • What treatment approach do you recommend?

What to expect from your doctor

Your doctor may ask you a number of questions, such as:

  • How long have you experienced symptoms?
  • Have your symptoms changed over time?
  • Do you experience breast pain? How severe?
  • Do you have nipple discharge? How would you describe the color, consistency and amount?
  • Do your symptoms occur in one or both breasts?
  • Have you had a fever?
  • When was your last mammogram?
  • Have you ever been diagnosed with a precancerous breast condition?
  • Have you ever had a breast biopsy or been diagnosed with a benign breast condition?
  • Has your mother, a sister or anyone else in your family had breast cancer?
  • What, if anything, seems to improve your symptoms?
  • What, if anything, appears to worsen your symptoms?

warts

Anal and Peri-Anal Warts   What are Anal Warts? Anal warts (condylomas) are small skin-colored or pink-colored growths or spots in or around the anus. These growths can become large and cover the entire anal area. Anal warts are one of the most common sexually transmitted infections in world. Four distinct sub-types of Ano-genital warts have been described: condylomata acuminata (pointed warts), flat / macular lesions, papular, and keratotic lesions. The first two sub-types are mainly found on moist, non-keratinized epithelia, while the latter two usually present on keratinized epidermis. Ano-genital warts are also often referred to as genital warts,…

  • GENITAL WARTS   A wart is a small growth with a rough texture that can appear anywhere on the body, it looks like a small cauliflower. All warts are caused by Human Papilloma Virus (HPV).     Genital Warts-Standard Treatment Guidelines Warts occuring on external genitalia are called genital warts. External genital warts are also known as condylomata acuminata. They are one of the most common forms of sexually transmitted diseases. Genital warts are single or multiple soft, painless, flat, papular, or pedunculated growths which appear around the anus, vulvovaginal area, penis, urethra and perineum. May also appear as keratinized papules. Common sites are Men: under the foreskin, on the shaft Women: around the introitus Both: On the anogenital epithelium,within the anogenital tract. High-risk human papillomaviruses (HPV 16 & 18 serotypes) cause essentially all cervical cancers, most anal and oropharyngeal cancers, and some vaginal, vulvar, and penile cancers.    Cutaneous (skin) HPV types Most HPV types are called cutaneous because they cause warts on the skin, such as on the arms, chest, hands, and feet. These are common warts, not genital warts. Mucosal (Genital or Anogenital) HPV types The other HPV types are considered mucosal types…

  • Warts Gallery   HPV virus infection of the skin with warts formation and HPV virus shedding           Electr-coagulation / Fulgration (Electrosurgery) of Penile warts     Fulguration of anal Warts

Stomach, Duodenum & Pancreas

Diseases of Colon and Rectum

Diseases of Anal Canal

Diseases of Scrotum and Testis

Diseases of Kidneys, ureter and urinary bladder

Surgery - The delicate art of blending science & nature

  • Dr. Pawan Lal 
  • Professor of Surgery
  • Maulana Azad Medical College
  • New Delhi
  • India
  • (Delhi University)

 

I have tried to enumerate the fine details of the surgical diseases and their management. For more information and constructive criticism,email me at: info@pawanlal.com

Dr. Pawan Lal
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