General and breast surgery for GPs: gallstones on weight-loss drugs, early cholecystectomy, appendicitis mistaken for diverticulitis, hernias and breast red flags

Speaker

General surgeon and breast surgeon — identified by role only. Otter labels them “Speaker 1”. They open by saying “I’m a general surgeon and breast surgeon.” No personal name is spoken. A GP in the room (Speaker 2) discusses a 52-year-old with a fixed breast mass and implant concerns; “Stacey” at the end appears to be for handwritten feedback forms, not the surgeon’s name.

Audience

GPs; brief warm-up from the room about dense-breast imaging (CRT / contrast-enhanced techniques) costing patients hundreds of dollars with reclaim friction — then the surgeon’s case series.

Session context

Otter title Surgical Case Discussion · id PpdeRF08MEnZNadLS57U1DPB6RE · ~18 min, recorded 21 March 2026 3:46 pm AEST. The Otter title is generic; the real content is gallbladder, skin, appendix, hernia and breast cases. Same CPD afternoon as the infertility seminar.

Key messages for GPs

• Weight-loss medications → gallstones. No routine screening mandate (as stated), but abdominal pain on these drugs → ultrasound for stones. Stones also present as cholecystitis or gallstone pancreatitis in ED.
• Operate early for acute cholecystitis when possible (days, not “wait weeks”). After about a week tissues are rigid and bile-duct injury risk rises. Diabetes predicts failure of conservative care (necrotic gallbladder case).
• Excise small sebaceous cysts before they become infected carbuncles needing VAC dressings and months of wound care.
• First-episode “diverticulitis” without prior CT or colonoscopy is a dangerous label. Several patients in the last few months had advanced appendicitis after a week of GP antibiotics.
• Trust the patient and re-query radiology when the story is classical appendicitis but the report says diverticulitis — you can have both, or a wrong call.
• Late-70s / early-80s hernias: consider fixing while still fit; laparoscopic repair can address the other side prophylactically (~1 in 4 may become symptomatic later — as stated).
• Sudden breast seroma with implants → think BIA-ALCL (especially textured implants, often 6–10+ years later): aspirate for cytology. Non-lactating mastitis in older women → image for occult cancer once cellulitis settles. Prefer needle aspiration over incision for lactating abscesses.

Warm-up: dense-breast imaging costs

Before the cases, someone in the room noted denser-breast adjunct imaging (ASR mentions CRT / similar) is still not widely reported locally. Cost talk: about $300 extra in one version; another pathway had patients paying around $600 up front and claiming back because the provider would not bulk-claim. Flagged as room chatter, not the speaker’s main topic.

Gallstones, weight-loss drugs and early cholecystectomy

With GLP-1-era weight loss, the speaker is seeing more stone disease — cholecystitis and gallstone pancreatitis in emergency. No current recommendation to screen everyone starting weight-loss meds, but if they develop abdominal pain, ultrasound for stones.

On timing of surgery for acute cholecystitis:

• Older teaching: antibiotics, wait weeks, operate later.
• Current preference (especially with private access): operate early so patients feel better sooner and tissues are less rigid.
• Ideal window is usually within a few days. Beyond about a week: very inflamed, friable, vascular tissue — higher risk of bile-duct injury (“damage to the milder” in ASR ≈ bile duct).
• Diabetes: less likely to settle conservatively. Case shown: man with necrotic (black) gallbladder — decompress with a trocar, suck bile/pus/stones, dissect Calot’s triangle (cystic duct and artery), cholangiogram, remove gallbladder.
• Contrast case: earlier presentation, less angry tissues, less diathermy needed.

Sebaceous cysts: small is easy, neglected becomes a carbuncle

GPs can usefully excise small sebaceous cysts. Case: man with long-standing back cysts; one became a carbuncle — not drainable as a simple abscess, excised as an inflamed mass (plus a smaller one). He declined a third “ticking time bomb”; six weeks later that one infected too. Antibiotics early allowed closure, but he still had a seroma, VAC dressing, hospital-in-the-home wound care, and about three months to heal — with a bad scar. Moral: deal with them when small.

“Diverticulitis” that was appendicitis

GPs see undifferentiated abdominal pain first. The speaker had multiple patients in the last three to four months told they had diverticulitis who:

• had never had diverticulitis before
• had never had a colonoscopy
• had never had a CT (in the speaker’s understanding of those histories)

Two shown on CT actually had appendicitis left a week — oral antibiotics, returned sicker, with a mass. Physiology: untreated appendicitis gets walled off by omentum; abscesses may need percutaneous drains; after about a week they often need prolonged IV antibiotics (these two had about a month of home IV), then colonoscopy to exclude malignancy, then interval appendicectomy — or sometimes right hemicolectomy if a faecalith / ongoing inflammation makes simple appendicectomy unsafe.

Third teaching case: nurse with classical appendicitis symptoms; CT reported diverticulitis; no left/suprapubic pain. After 24 hours of antibiotics she still felt terrible. Speaker phoned radiology — appendix also looked inflamed. Theatre: appendicitis. Lesson: reports can be wrong; dual pathology exists; clinical course trumps the first read.

Incidental and contralateral groin hernias

• Hernias are common; older patients accrue comorbidity — sometimes better to fix while still fit (late 70s / early 80s) than wait until emergency or unfitness.
• If one groin hernia is found, consider imaging the other side. Laparoscopic repair opens a plane that can address both sides; discuss prophylactic contralateral mesh — pain risk on an asymptomatic side, but about a quarter may become symptomatic later (as stated).
• Speaker prefers staying outside the peritoneum (TEP-style) so mesh does not contact bowel, working in the plane behind the rectus.

Breast: implants, mastitis and lactating abscesses

Implant-associated lymphoma (BIA-ALCL framing)

Sudden seroma in a breast with implants is worrying because of lymphoma associated with breast implants (speaker’s framing; typically linked to textured implants, often around 6–10 years or longer). Diagnose by aspirating fluid for cytology.

Case: woman with old augmentation, later breast-conserving surgery + radiotherapy → capsular contracture → implant exchange; decades later pancreatic cancer plus a suddenly huge swollen breast. Team feared implant lymphoma (textured implants); it was a liquefied haematoma / seroma on anticoagulation. Implants and capsule still had to come out so she could have chemotherapy.

Mastitis outside childbearing age

Woman in her 70s admitted with extremely painful mastitis, no recent imaging. She turned out to have breast cancer on that side — lumpectomy, sentinel node, radiation. Message: after cellulitis settles in older / non-lactating women, arrange mammogram and ultrasound — opportunistic cancer detection.

Lactating breast abscess

First-time mum needed formal debridement of bilateral lactating abscesses — “really bad to debride a lactating breast” because cutting causes ongoing milk leak. Prefer antibiotics + needle aspiration. This patient needed milk suppression (ASR “doster next” ≈ cabergoline / dopamine agonist class as used locally) and prolonged dressings.

Q&A: swollen breast after implants and hard-to-get MRI

A GP described a 52-year-old leaving a domestic-violence situation, implants for ~15 years, one breast larger for over a year, now a ~10 cm mass fixed to chest wall. ED apparently suggested possible capsule rupture and sent her home; getting Medicare-funded MRI was difficult. Speaker agreed it is worrying; if mammogram is hard with implants, a chest CT (not ideal) can be a cheaper way to look for a large mass while advocacy for proper breast imaging continues. Fixed, progressive asymmetry is not “just rupture” until proven otherwise.

GP clinic checklist

1. Abdominal pain on weight-loss medication → ultrasound for gallstones.
2. Acute cholecystitis → early surgical referral; don’t assume “cool down for weeks,” especially in diabetes.
3. Offer excision of small sebaceous cysts before they become carbuncles.
4. First-label diverticulitis without imaging history → low threshold for ED/CT if not better in a day.
5. Classical appendicitis + discordant CT → call radiology / surgical review.
6. Discuss elective hernia repair while older patients are still fit; mention contralateral findings if laparoscopic.
7. Implant + sudden swelling → urgent aspirate for cytology; older mastitis → image after settling; lactating abscess → aspirate first.
8. Fixed breast mass / marked asymmetry with implants → do not accept “possible rupture” without a clear cancer-excluding pathway.

Transcript caveats

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