Peritoneal Encapsulation - A Rare Cause of Small Bowel Obstruction.

Peritoneal encapsulation (PE) is a rare anatomic anomaly which occurs due to an accessory peritoneal sac covering the small bowel which can cause chronic recurrent abdominal pain and even small bowel obstruction, most often in children or patients with no previous surgical history. The diagnosis is usually made during surgery, but recently it has been suggested that mindful examination of the abdominal CT may be helpful in considering PE beforehand. We present the case of a 21-year old patient who was admitted due to intense abdominal pain, asymmetrical abdominal distension, air fluid levels on the abdominal X-ray, but no specific findings on the abdominal CT. He underwent emergency surgery and PE was found and the peritoneal sac was excised. The postoperative course was uneventful. Histopathologic examination of the specimen confirmed the diagnosis. PE is often misdiagnosed as abdominal cocoon or sclerosing encapsulating peritonitis, but it is a pathology with a much lower rate of recurrence and postoperative complications, which can be treated successfully if the surgeon is aware of this pathology when making the differential diagnosis.

Imaging of the pediatric peritoneum, mesentery and omentum.

The normal peritoneal structures, including the mesenteries and the omenta, are only a few cell layers thick and are visible on imaging based upon the tissues (e.g., fat) and structures (e.g., blood vessels and lymph nodes) contained within them. These structures become more visible and change in appearance when involved by pathological processes. In this pictorial essay, we discuss the normal anatomy of the various abdominopelvic peritoneal structures and illustrate numerous developmental and acquired diagnoses that involve these structures in the pediatric and young adult population.

Cysts of the canal of Nuck: A rare sonographic diagnosis.

The canal of Nuck is a remnant of a peritoneal evagination associated with the round ligament in women. Rarely, the canal of Nuck can remain patent allowing for development of cysts. These cysts are difficult to diagnose due to their rare incidence and because they are often mistaken for other causes of inguinal pain in women. This case series of three women presenting with groin or labial masses highlights the role of sonography as the primary imaging modality in the diagnosis of canal of Nuck cysts. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:175-178, 2017.

[Recent advances in miR-200c and fibrosis in organs].

In the fibrosis and pterygium of lung, liver, kidney, peritoneum or skin, miR-200c was aberrantly expressed. It has been shown that the regulatory effect of miR-200c on fibrosis in organ was involved in TGF-ß-mediated epithelial-mesenchymal transition. The abnormal level of miR-200c in serum may be a basis for early diagnosis of lung fibrosis. Furthermore, miRNA mimics, miRNA agomir, and miRNA inhibitor are potential therapeutic tools for fibrosis. In present review, we summarize the recent progress in relevant studies on the expression and regulatory function of miR-200c and focus on its role in diagnosis, treatment, and prognosis of fibrosis in organ.

Comparison of Two Techniques of Laparoscopy-Assisted Peritoneal Vaginoplasty.

Neovagina creation is essential for patients with the Mayer-Rokitansky-Kuster-Hauser syndrome. We compared a technique involved the pushing down of the peritoneum with the technique of separating the peritoneum for laparoscopy-assisted peritoneal vaginoplasty. We collected patients with congenital absence of vagina who underwent laparoscopy-assisted peritoneal vaginoplasty of the First Affiliated Hospital of Zhengzhou University between January 2011 and May 2013. The 2 surgical groups (pushing group and separating group) were compared for various parameters. The values of the following parameters were significantly lower for the pushing group compared with the separating group: mean operating time (78 ± 13 minutes vs 135 ± 28 minutes), mean duration of hospitalization (12.9 ± 2.7 days vs 18.0 ± 3.8 days), mean cost of hospitalization (14 016 ± 1640 RMB vs 18 783 ± 2143 RMB), requirement for a drainage tube (4% vs 27%; χ(2) = 8.864), requirement for analgesic drugs (20% vs 40%; χ(2) = 3.977), and postoperative rehospitalization (3.3% vs 10.0% at 2 months and 6.7% vs 26.7% at 6 months; χ(2) = 4.268 and 5.196). Mean values for blood loss (57 ± 19 mL vs 66 ± 20 mL), time to pass gas (21 ± 4 hours vs 23 ± 7 hours), and length of the reconstructed vagina (9.0 ± 0.4 cm vs 8.9 ± 0.5 cm) were not significantly different between the 2 groups. In addition, mean postoperative Female Sexual Function Index score did not differ significantly between the 2 groups or among the 2 groups and a control group (27.0 ± 4.8 vs 26.7 ± 5.2 vs 27.9 ± 4.5; p > .05). The technique involving pushing down of the peritoneum offers advantages of reduced cost, complications, hospitalization, operative time, and pain over the traditional technique. Sexuality approaches so-called "normal" sexuality.

Nonobliteration of the Processus Vaginalis. Sonography of Related Abnormalities in Children.

The objective of this pictorial essay is to systematically classify processus vaginalis­ related disorders in the light of embryology and present illustrative sonograms with corresponding diagrams. Failure of the processus vaginalis to obliterate during gestation results in a wide spectrum of anomalies, including communicating and noncommunicating hydroceles and inguinal and inguinoscrotal hernias, along with other related disorders of the genital system. There are varying classifications in the literature regarding the aforementioned entities. Proper and timely diagnosis of these entities is essential, given the differences in treatment. Although physical examination can narrow the differential diagnosis, sonography plays an essential role in establishing the diagnosis.

[Pathology of the processus vaginalis in urological practice]. / La pathologie du canal péritonéo-vaginal en pratique urologique.

PURPOSE: To describe the epidemiological, anatomico-clinical and therapeutic aspects of the patent vaginoperitoneal canal (PVPC) in urological practice and to compare our results with those of pediatric teams. PATIENTS AND METHODS: We performed a retrospective descriptive study of PVPC cases operated in a urology unit. The following parameters were studied: medical history, age, method of installation, the anatomo-clinical type, side and the results of the treatment. RESULTS: A total of 163 cases were collected over a period of 5 years. The average age was 7.5 ± 7 years with a range of 2 months and 39 years. Thirty-four patients had less than or equal to age 2 ears and 28 patients were adults. The reason for consultation was an inguinal or scrotal inguinal, painless and intermittent swelling in 72.3% of cases. Installation mode was progressive in 45 patients (27.6%). The PVPC was sitting right in 81 patients (49.7%) and was bilateral in 12 patients (7.3%). The anatomo-clinical types were dominated by the communicating hydrocele (52%). The treatment was carried out in controlled surgery in all patients and the mean duration of hospitalization was 24 hours. The postoperative course was marked by 5 cases of scrotal hematoma and 2 cases of parietal suppuration. Postoperative mortality was zero. After a mean postoperative decrease of 2 years we observed 3 cases of testicular atrophy and two recurrences. CONCLUSION: Our results in terms of morbidity and mortality although satisfactory were lower than those of pediatric teams. LEVEL OF EVIDENCE: 5.

Unification and orificing of two functional noncommunicating uterine horns through the created neovagina using peritoneum.

OBJECTIVE: To demonstrate the surgical approach for Müllerian agenesis with bilateral uterine remnants containing functional endometrium. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Reproductive surgery unit of a tertiary university hospital. PATIENT: An 18-year-old adolescent was admitted to a tertiary university hospital with complaints of primary amenorrhea and cyclic pelvic pain. Physical examination and magnetic resonance imaging scans suggested a complex Müllerian abnormality. The patient had uterine remnants with bilateral functional endometrium and cervicovaginal agenesis. INTERVENTION: An operation was planned to reconstruct her anatomy by providing a neovagina and anastomosing the uterine remnants. Gonadotropin-releasing hormone analogs were prescribed to suppress her menstruation until the procedure. The operation was performed in the third month after the initial diagnosis. A laparoscopy was conducted, revealing approximately 5 × 6-cm bilateral uterine horns with healthy adnexa. As the first step, a neovagina was created using a modified peritoneal pull-down technique, a standard approach in our clinic. A vaginal incision was made, and a blind vaginal dissection was performed to reach the peritoneum vaginally. Subsequently, an acrylic vaginal mold was inserted. The vaginal orifice was laparoscopically incised using ultrasonic energy with guidance from the inserted vaginal acrylic mold. The orifice was gradually dilated with larger molds. The entire pelvic peritoneum was dissected circularly, and the distal part of the dissected peritoneum was pulled down using four 2.0 Vicryl sutures at 0°, 90°, 180°, and 270° from the opened vaginal orifice. The uterine cavities of both remnants were incised, and two separate Foley catheters were placed in both cavities. A mold with a hole was used to insert the catheters through the vagina. Both catheters were secured in the cavities with Prolene sutures pulled up from the anterior abdominal wall. The next step involved uterine anastomosis. The uterine remnants were unified through continuous suturing, resulting in the formation of a normally shaped uterus. In the final step, the created uterus and neovagina were anastomosed. The patient received instructions on how to perform mold exercises and follow-up care. MAIN OUTCOME MEASURE: Description of laparoscopic management of a rare Müllerian abnormality. RESULTS: The postoperative magnetic resonance imaging scan at 1 month revealed healed unified uterine cavities and vagina. The patient experienced spontaneous menstruation in the second month after surgery and now maintains regular menses with an approximately 9-10 cm functional vagina. Within 3 months after surgery, the visual analogue scale scores for chronic pelvic pain and dysmenorrhea decreased from 9 to 2-3. CONCLUSIONS: Müllerian abnormalities are exceptionally rare, and their spectrum is broad, making it challenging to identify an exact surgical method to restore functional anatomy. Therefore, a customized surgical approach should be designed for each patient on the basis of their unique condition.

Small bowel obstruction due to anomalous congenital peritoneal bands - case series in adults.

BACKGROUND: Congenital bands cause 3 % of all intestinal obstruction and almost always lead to small bowel obstruction. In adults, obstruction due to bands is even rarer. MATERIALS AND METHODS: A multicenter study in Turkey. From January 2000 to December 2010 inclusive - a period of 10 years - all adult patients admitted to the emergency departments with a clinical diagnosis of acute intestinal obstruction due to congenital peritoneal band were included in the study. Surgery was defined as emergency. Recorded operative findings included the site of obstruction, and the operative procedure to relieve it. In the present study, the findings in adult patients with congenital band reported in the literature together with findings in ten cases operated at four center were retrospectively assessed with respect to their demographic, preoperative, peroperative, and postoperative characteristics. RESULTS: There were 8 males and 2 females aged between 18 and 72 year. There were no history of abdominal or inguinal surgery. Plain abdominal X-rays radiography revealed air- fluid levels in all patients. All the bands were ligated and divided. On histopathological examination, the bands were composed of loose connective tissue containing blood vessels. There were no calcification in the bands. CONCLUSION: an anomalous congenital band could be included in the differential diagnosis of intestinal obstruction. This clinical situation requires early surgical intervention that will be diagnostic and therapeutic (Tab. 1, Fig. 4, Ref. 21).

Peritoneal encapsulation presenting as small bowel obstruction in a 16 year old girl.

Peritoneal encapsulation is a rare congenital anomaly characterized by a thin membrane of peritoneum encasing the small bowel to form an accessory peritoneal sac. Cases usually present with small bowel obstruction or can be an incidental finding during laparotomy. We report a case of peritoneal encapsulation presenting as a small bowel obstruction in a 16 year old girl. The sac was easily excised and surgery was otherwise uneventful. A discussion of the case and review of literature is presented.

Accidental identification of peritoneal encapsulation during an autopsy after a car accident.

Peritoneal encapsulation is a rare congenital pathological condition. Typical of this pathology is the presence of an accessory peritoneal flap that encloses the entire mass of the small intestine. Subjects with this condition often do not show symptoms and, in most cases, finding of it is accidental. We report a case of peritoneal encapsulation, not previously identified and found during an autopsy; the deceased, positive for HIV and affected by a Kaposi's sarcoma, died following a road accident. Unlike other cases in the literature, the peritoneum encapsulated all abdominal organs and not only small intestines. Notwithstanding, there were no signs of intestinal ischaemia or intestinal obstruction.

Recent developments in the genetic factors underlying congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is a birth defect affecting around 1 in 3,000 births and is associated with high mortality and morbidity. It has become increasingly apparent that genetic factors underlie many forms of CDH. We review the recent developments in the area of the genetics of CDH, including potential candidate genes supported by evidence from animal models. We also discuss the possible role in the pathogenesis of CDH of defective retinoid signalling and abnormal mesenchymal cell function.

The significance of post-radiotherapy parametrial involvement and the necessity of parametrial resection in locally-recurrent or persistent cervical cancer developed after radiotherapy.

OBJECTIVE: To retrospectively evaluated the prognostic significance of post-radiotherapy parametrial involvement (PMI), the necessity of parametrial resection, and the optimal salvage surgery in locally recurrent or persistent cervical cancer developed after radiotherapy. METHODS: Patients who developed recurrent or persistent cervical cancer in a previously irradiated field and were subsequently treated with salvage surgery were identified, and the prognostic impact of post-radiotherapy PMI on patient's survival was first investigated. Then, the optimal salvage surgery for patients with post-radiotherapy PMI as well as the predictors for post-radiotherapy PMI were evaluated. RESULTS: A total of 60 patients underwent salvage surgery for recurrent or persistent diseases. Of these, 21 (35.0%) showed post-radiotherapy PMI (PMI-group). Patients in PMI-group showed significantly shorter progression-free survival (PFS) than those in non-PMI-group (p = 0.01). In both PMI-group and non-PMI-group, PFS was affected by the completeness of salvage surgery. In non-PMI-group, less radical surgery achieved similar therapeutic efficacy to more radical surgery (3-year PFS rates: 62.5% versus 54.1%, p = 0.91). In contrast, in PMI-group, not less radical surgery but more radical surgery achieved curative therapeutic efficacy (3-year PFS rate: 0% versus 28.9%). Maximum tumor diameter, deep stromal invasion, and LVSI were found to be predictors of post-radiotherapy PMI. CONCLUSION: Post-radiotherapy PMI is an indicator of short survival after salvage surgery in patients with locally recurrent or persistent cervical cancer developed after radiotherapy. Both less radical and more radical surgery have curative therapeutic efficacies in patients without post-radiotherapy PMI, if the tumor could be resected with an adequate surgical margin. Thus, hysterectomy type should be tailored to the risk for post-radiotherapy PMI.

Early development of the primordial mammalian diaphragm and cellular mechanisms of nitrofen-induced congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is a frequently occurring cause of neonatal respiratory distress and is associated with high mortality and long-term morbidity. Evidence from animal models suggests that CDH has its origins in the malformation of the pleuroperitoneal fold (PPF), a key structure in embryonic diaphragm formation. The aims of this study were to characterize the embryogenesis of the PPF in rats and humans, and to determine the potential mechanism that leads to abnormal PPF development in the nitrofen model of CDH. Analysis of rat embryos, and archived human embryo sections, allowed the timeframe of PPF formation to be determined for both species, thus delineating a critical period of diaphragm development in relation to CDH. Experiments on nitrofen-exposed NIH 3T3 cells in vitro led us to hypothesize that nitrofen might cause diaphragmatic hernia in vivo by two possible mechanisms: through decreased cell proliferation or by inducing apoptosis. Data from nitrofen-exposed rat embryos indicates that the primary mechanism of nitrofen teratogenesis in the PPF is through decreased cell proliferation. This study provides novel insight into the embryogenesis of the PPF in rats and humans, and it indicates that impaired cell proliferation might contribute to abnormal diaphragm development in the nitrofen model of CDH.

The International Pediatric Endosurgery Group Evidence-Based Guideline on Minimal Access Approaches to the Operative Management of Inguinal Hernia in Children.

Introduction: Minimally invasive surgery (MIS) for inguinal hernia repair (IHR) in children has been reported for more than two decades. The International Pediatric Endosurgery Group (IPEG) Evidence-Based Review Committee chose MIS IHR as the inaugural topic for review and presentation at the 2016 IPEG annual meeting. Materials and Methods: English language articles published between January 1, 2009, and December 31, 2015, were reviewed and included in this evidence-based review after searching PubMed, Cochrane Reviews, ClinicalTrials.gov, Google Scholar, and EMBASE. Results: Level 1a and 1b evidence supports the recommendations that operative time for bilateral IHRs should be considered shorter and postoperative complications rates should be considered lower in MIS repair over open. Recurrence rates are similar between the two methods (level 1a and 1b evidence). No level 1 evidence exists to support one MIS technique over another or that operating on a detected contralateral patent processus vaginalis during laparoscopy makes any difference in long-term outcome to the patient. Conclusions: The advantages of lower postoperative complications and shorter operative times have been found in studies of surgeons experienced in MIS repair and differences were small. The evidence in this review supports that MIS repair is a safe, effective method of IHR with proper training and mentorship.

Abnormal peritoneal fold connecting the greater omentum with the liver, gallbladder, right kidney and lesser omentum.

Abnormal peritoneal folds near the liver are very rare. This case report presents an observation of an abnormal fold of peritoneum that extended from the upper right part of the greater omentum and stomach to the fossa for gallbladder. This fold merged with the lesser omentum on the left and extended to the right kidney when traced posteriorly. The epiploic foramen was entirely absent due to the presence of this fold. However, the lesser sac was there behind the liver, lesser omentum and stomach. The knowledge of abnormal folds like this may be important for surgeons (Fig. 3, Ref. 7). Full Text (Free, PDF) www.bmj.sk.