Caseating granulomata caused by hemostatic agent posing as metastatic leiomyosarcoma.

BACKGROUND: As the number of minimally invasive and laparoscopic procedures increases, hemostatic agents are becoming more popular as a means of achieving rapid hemostasis. CASE REPORT: The patient is a 61-year-old woman who underwent a laparoscopic supracervical hysterectomy. FloSeal Hemostatic Matrix (Baxter Healthcare, Deerfield Illinois) was used at the conclusion of the procedure. RESULTS: Pathology unexpectedly revealed high-grade leiomyosarcoma of the uterus. The patient then presented to our facility for consultation and was scheduled for robotic trachelectomy and lymphadenectomy. Laparoscopy revealed nodular lesions throughout the abdomen and pelvis. Biopsies were performed and the case aborted. Final pathology however showed caseating foreign body giant cell granulomata in all specimens. No malignancy was found. The patient then underwent exploratory laparotomy, trachelectomy, and a staging procedure. All pathology specimens and pelvic washings were negative for malignancy. CONCLUSIONS: Use of gelatin-thrombin hemostatic agents may elicit a foreign body reaction leading to large giant cell granulomata. In this case, the presence of these granulomata mimicked metastatic disease.

Colouterine fistulas in elderly women: a report of 2 cases.

BACKGROUND: Colouterine fistula is a rare complication of diverticulitis. We report 2 cases of colouterine fistula in elderly women presenting with fever and pyuria and managed with an aggressive workup and surgical treatment. CASES: Two elderly women presented with persistent pyuria, abdominal pain and fever without a vaginal discharge. Imaging revealed diverticulitis and a fistula. One patient, 92 years of age, underwent hysterectomy, sigmoid resection and primary colorectal anastomosis. The second patient, aged 87, was treated with hysterectomy, sigmoid resection and diverting colostomy with delayed colostomy closure. CONCLUSION: Colouterine fistula may present with pyuria, fever and abdominal pain even in the absence of vaginal discharge. Patients who are elderly and fragile are more likely to be treated conservatively and inappropriately. We advocate surgical management, including resection of all involved tissue, early in the course of the disease. In elderly women, aggressive 1- or 2-stage procedures are highly successful and could save the patients' lives.