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Pathology and operative strategy
  1. A Reddi
  1. Correspondence to:
 Mr A Reddi, Department of Cardiothoracic Surgery, Wentworth Hospital, Nelson R Mandela School of Medicine, University of Natal, Durban, South Africa;

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What if a preoperative diagnosis is unavailable?

As a general principle, in elective surgery, it is considered advisable to establish a pathological diagnosis (by cytology or histology, and occasionally by microbiological means) before the removal of a lesion, with or without the associated organ or part thereof. The rationale for this approach is obvious: to rule out the possibility of an alternative form of treatment—that is, a more conservative one—that will obviate the need for surgical resection. Take—for example, endobronchial tuberculosis, which may on clinical, radiographical, and endoscopical grounds be indistinguishable from bronchial carcinoma. In this instance, to remove a lung or lobe without histological confirmation would clearly be catastrophic. However, it is not always possible to obtain tissue for preoperative diagnosis. Inaccessible organs/lesions or the invasive nature of the diagnostic manoeuvre may make the procedure hazardous, with a statistically significant morbidity and, occasionally, even mortality. Under these circumstances, the clinician may have to resort to an amalgam of clinical, radiographical, and ancillary biochemical investigations for a diagnosis. Where the treatment is deemed surgical, even without a definitive pathological diagnosis, the surgeon is justified in resection of the lesion (with or without the associated viscous), based on a provisional diagnosis. Tissue diagnosis by frozen section is thought advisable, although less reliable than a paraffin wax embedded section.

A wide variety of medical personnel, influenced by local practices and available expertise, undertake minor diagnostic procedures (usually without the need for a general anaesthetic). Where fee for service structures exist, the incentive for financial remuneration may determine the investigator. This “generalist” approach to diagnosis is acceptable where the manoeuvre is relatively simple and innocuous and the diagnostic yield is high irrespective of the technical …

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