[Interdisciplinary position paper "Perioperative pain management"]. / Interdisziplinäres Positionspapier "Perioperatives Schmerzmanagement".

Despite many positive developments, postoperative pain and its treatment is still not always given the necessary attention. Severe pain after surgical procedures affects a significant proportion of patients. This very fact is not only detrimental to the immediate recovery process, but can also form the basis for the development of chronic pain conditions.An adequate and effective management of perioperative pain requires appropriate organizational structures. This multidisciplinary paper which was initiated by the Austrian Society for Anaesthesiology and Intensive Care and the Austrian Pain Society and developed together with numerous specialist and professional societies dealing with the subject aims at supporting the organization of perioperative pain management structures and to make best use of proven concepts. Additional recommendations describe specific interventions for selected types of intervention.

Transanal drainage tube reduces rate and severity of anastomotic leakage in patients with colorectal anastomosis: A case controlled study.

BACKGROUND AND AIMS: The aim of this study was to investigate the clinical usefulness of the placement of a transanal drainage tube to prevent anastomotic leakage in colorectal anastomoses. MATERIAL AND METHODS: This single-center retrospective trial included all patients treated with surgery for benign or malign colorectal disease between January 2009 and December 2012. The transanal drainage tube was immediately placed after colorectal anastomosis until day five and was routinely used since 2010. Patients treated with a transanal drainage tube were compared with the control group. Statistical analysis was performed using Fisher's exact or Chi-square tests for group comparison and a linear regression model for multivariate analysis. RESULTS: This study included 242 patients (46% female; median age 63 years; range 18-93); 34% of the patients underwent a laparoscopic procedure, and 57% of the patients received a placement of a transanal drainage tube. Anastomotic leakage occurred in 19 patients (7.9%). Univariate analysis showed a higher rate of anastomotic leakage in patients with an ASA score 4 (p = 0.02) and a lower rate in patients with transanal drainage placement (3.6% vs. 13.6%; p = 0.007). The grading of the complication of anastomotic leakage was reduced with transanal drainage (e.g., Dindo â‰§ 3b: 20.0% vs. 92.9%; p = 0.006), and the hospital stay was shortened (17.6 ± 12.5 vs. 22.1 ± 17.6 days; p = 0.02). Multivariate analysis revealed that transanal drainage was the only significant factor (HR = -2.90; -0.168 to -0.032; p = 0.007) affecting anastomotic leakage. CONCLUSIONS: Placement of a transanal drainage tube in patients with colorectal anastomoses is a safe and simple technique to perform and reduces anastomotic leakage, the severity of the complication and hospital stay.

[Single Incision Laparoscopic Cholecystectomy (SILC) - A Novel Technique in Comparison with the Gold Standard]. / Single-Port-Cholezystektomie: Ein Vergleich mit dem Goldstandard.

BACKGROUND: Currently multiport laparoscopic cholecystectomy (LC) represents the gold standard for gall bladder removal. However, a single-incision approach might succeed it as the future leading technique. To date, final proof for safety and applicability remain elusive. METHODS: A retrospective analysis of prospectively collected data from 459 patients subjected to multiport (LC) or single incision laparoscopic cholecystectomy (SILC) was performed. RESULTS: From 2010 to 2011, 115 SILC (25 %) and 344 LC (75 %) interventious were performed. Mean follow-up was 13.2 (2.1/24.6) months. The SILC group comprised more females (SILC: m : f 1 : 3.4 vs. LC: 1 : 1.2) and younger patients (SILC: 44.7 vs. LC: 54.9 years) with a slightly lower (ASA) score (SILC:1.7 ± 0.3 vs. LC:1.9 ± 0.5). SIL cholecystectomy was performed more frequently in an elective setting (SILC: 81.7 vs. LC: 55.5 %). Complication rates were low and did not differ significantly between groups (wound infections: SILC: 2.3 vs. LC: 3.19 %; incisional hernias: SILC: 0.86 vs. LC: 2.3 %, bile leakage: SILC: 0.86 vs. LC: 0.57 %). SILC was associated with shorter operative times (SILC: 70 ± 31 vs. LC: 80 ± 27 minutes; p < 0.001) and reduced postoperative hospital stay (SILC: 3.02 ± 1.4 vs. LC: 4.6 ± 2.8 days; p < 0.001). No conversion to open surgery was required with SILC when compared to LC (6 %; 21/334). Within the SILC group, additional ports had to be placed in 2.6 % (3/115). CONCLUSION: SILC displays a minimised surgical trauma. Compared to LC, SILC showed no disadvantage concerning risk profiles, operative times or hospital stay. We believe that SILC can be regarded as a natural evolution in the era of minimally invasive surgery.

Significant weight loss and rapid resolution of diabetes and dyslipidemia during short-term follow-up after laparoscopic sleeve gastrectomy.

BACKGROUND: Bariatric surgery has been established as the best option of treatment for morbid obesity. Recently, laparoscopic sleeve gastrectomy (SG) has become very popular because of good postoperative weight loss and low morbidity. The aim of this study was to report our single-center experience with SG regarding feasibility, morbidity, and outcome. METHODS: From January 2006 to December 2011, 93 patients (68 female) with a median age of 46 years underwent laparoscopic SG at our department. Thirteen patients had a history of gastric banding with insufficient weight loss or band-related complications. Clinical outcome and laboratory findings were analyzed. RESULTS: The mean preoperative and postoperative body mass index (BMI) was 44.1 ± 6.9 and 33.4 ± 6.8 kg/m(2), respectively (p < 0.001). The mean excessive body weight loss after a median follow-up of 11.9 months was 55.7 % ± 24.9 %. Three bleedings, two staple line leakages, and a deep wound infection required conversion to laparotomy (n = 1), reoperation (n = 4), or endoscopic stent implantation (n = 2). Resolution of diabetes and dyslipidemia was seen in 85 and 50 % of patients, respectively. Blood test results of HbA1c, cholesterols, triglycerides, and leptin showed significant postoperative improvement. CONCLUSIONS: Laparoscopic SG represents a feasible bariatric procedure with good short-term weight loss, low morbidity rate, and efficient resolution of diabetes and dyslipidemia, especially in patients with lower BMI. The significant decrease of leptin necessitates further studies to understand the ambiguous role of leptin in bariatric surgery.

Long-term effects of weight loss after bariatric surgery on functional and structural markers of atherosclerosis.

OBJECTIVE: Pronounced weight loss after bariatric surgery was demonstrated to have significant beneficial effects on surrogates of early atherosclerosis. The aim of this prospective examination was to investigate whether these improvements of endothelial function and vascular structure are persistent in the long-term. DESIGN AND METHODS: A total of 52 obese adults were examined before and 5 years after bariatric surgery. Carotid intima media thickness (IMT), brachial flow-mediated dilation (FMD), abdominal fat distribution, and metabolic parameters were determined. Additional 18 months data were available from 27 patients. RESULTS: After 5 years, mean weight loss ± SD of 25% ± 12 in all subjects was accompanied by known improvements in metabolism. Change in IMT was -0.02 mm ± 0.007, whereas FMD improved by +1.5% ± 0.5. In the subgroup IMT decreased by 0.04 mm ± 0.06 within the first 18 months, whereas no significant change was observed between 18 month and 5 years. FMD improved by 3.8% ± 0.6 after 18 months followed by a nonsignificant decrease of -1.4% ± 0.9. CONCLUSIONS: These long-term results demonstrate that bariatric surgery-induced weight loss improves both functional and structural markers of early atherosclerosis providing further evidence for the beneficial effects of weight loss on obesity-associated alterations of the vasculature.

[Pancreatic neuroendocrine tumour - laparoscopic distal pancreatectomy with splenectomy and partial gastric resection]. / Laparoskopische Pankreaslinksresektion mit Splenektomie und Magenteilresektion wegen eines neuroendokrinen Tumors.

PURPOSE: In selected patients laparoscopic distal pancreatectomy with splenectomy has increasingly gained in importance as an alternative to the open approach. Modern imaging procedures detect more frequently neuroendocrine pancreatic tumours. A typical feature of the neuroendocrine pancreatic tumour is that this kind of tumour is mostly small with a size of 1 to 2 cm. Due to their mostly small size they are suited to a laparoscopic approach. We report here the feasibility and surgical technique of a laparoscopic distal pancreatectomy with splenectomy and partial gastric resection due to a neuroendocrine pancreatic tumour. INDICATION: We describe a 74-year-old asymptomatic man (BMI: 28 kg/m2) with a 1.5 cm neuroendocrine tumour in the tail of the pancreas. METHOD: Laparoscopic distal pancreatectomy with splenectomy was performed using the 4-trocar technique in the 45-degree right lateral position. Due to a suspected tumour located at the greater curvature additionally a partial gastric resection was performed. Operative time was 184 min and intraoperative blood loss was 50 ml. The postoperative values of lipase and amylase in drainage were normal. No intraoperative or postoperative complications were recorded. The patient convalesced without complication and went home 7 days after surgery. CONCLUSION: Laparoscopic distal pancreatectomy with or without splenectomy is feasible with a low morbidity rate by experienced laparoscopic surgeons. The advantages of laparoscopic compared to open approach are well known, but the laparoscopic approach in pancreatic surgery should be used in selected patients. Due to their mostly small size, especially neuroendocrine tumours in the tail of the pancreas are suited to a laparoscopic approach.

[Single incision laparoscopic sigmoidectomy SILS sigmoidectomy]. / Laparoskopische Single-Inzisions-Sigmaresektion.

PURPOSE: Laparoscopic colon resection has several proven advantages over open surgery including postoperative pain, early recovery and better cosmesis. Single-incision laparoscopic (SIL) surgery, the most recent development in minimally invasive surgery, allows operations to be carried out through only a single incision using special ports. SIL surgery combines in part the cosmetic advantage and decreases the parietal trauma of natural orifice surgery, but allows operative realisation with standard and validated laparoscopic instruments. We report here the feasibility and surgical technique of a transumbilical SIL sigmoidectomy. INDICATION: We describe a 40-year-old man (BMI 30 kg/m2) with previously documented diverticular abscess and recurrent diverticulitis. METHOD: The multichannel 50-mm single port (OCTO-Port®, AFS Medical, Austria) was placed at the umbilicus. Transumbilical SIL sigmoidectomy was feasible with conventional laparoscopic instruments. Operative time for SIL sigmoidectomy was 159 min. A total of 25 cm sigmoid was resected. Oral diet was resumed on postoperative day one. No intraoperative or postoperative complications were recorded. The patient convalesced without complication and went home 6 days after surgery. At the 1-month review, he was fully recovered and his single umbilical scar was well healed. CONCLUSION: Transumbilical SIL sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. Further studies are certainly warranted for this promising technique. It has to be determined whether SIL offers benefit to the patient, besides cosmesis, compared with standard laparoscopic sigmoidectomy.

Laparoscopic gastric re-banding versus laparoscopic gastric bypass as a rescue operation for patients with pouch dilatation.

BACKGROUND: The authors assessed whether laparoscopic rebanding or laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the best approach for failed gastric banding after pouch dilatation. METHODS: Between January 2000 and June 2005, 489 patients underwent laparoscopic gastric banding, and of these, 33 (6.7%) required rescue procedures for pouch dilatation. Each reoperated patient was contacted to obtain information about their postoperative course. Additionally, preoperative weight and BMI, weight loss at 1 year postoperatively, weight at time of pouch dilatation and the time-period between the primary operation and pouch dilatation were analyzed. RESULTS: The most common operation for pouch dilatation was band repositioning or rebanding (16 patients). Band removal without replacement was performed in 7 patients. 8 patients underwent conversion to a LRYGBP. 1 patient underwent laparoscopic gastric sleeve resection and 1 patient received an intragastric balloon. Patients who underwent conversion to LRYGBP are very content and, although weight loss has been nearly the same as after gastric banding, they would prefer the gastric bypass operation to the gastric banding. CONCLUSION: Conversion to LRYGBP appears to offer significant advantages, and appears to be the rescue therapy of choice after failed laparoscopic gastric banding.

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES).

BACKGROUND: The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery. METHODS: A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued. RECOMMENDATIONS: After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Mechanical resistance of gastric bands - comparison between new bands and bands within the patient for at least two years.

BACKGROUND: Morbid obesity is a rapidly increasing health risk in industrialized countries, and is associated with serious co-morbidities. Since conservative medical therapies fail to sustain significant weight loss, adjustable gastric banding (AGB) has become an established therapy for morbid obesity. To our knowledge there have been no trials assessing whether gastric bands implanted in the patient for some time can withstand the same mechanical stress as a new band. METHODS: The mechanical resistance of unused and used gastric bands was tested through the Tensile Test, to evaluate if a material is strong and rigid enough to withstand the loads experienced in use. 9 bands were tested, 2 of which were unused. RESULTS: The tested new Swedish AGB (SAGB) resisted 361 Newtons (N, 36.8 kg) until tearing, and the new LAGB (Inamed) 157 N (16 kg). The 7 SAGB which had been in a patient for at least 2 years, pulled apart at a mechanical stress of 250.6 N (25.54 kg). CONCLUSION: The new SAGB had a higher mechanical tensile strength than any of the used bands placed in the body for 2 years.

Adjustable gastric banding: assessment of safety and efficacy of bolus-filling during follow-up.

BACKGROUND: Individual band-filling on demand of the morbidly obese patient is a major advantage of adjustable gastric banding. An increasing number of patients results in an enormous amount of outpatient follow-up visits, which inspired us to compare a stepwise band-filling strategy with a single bolus injection 4 weeks after the operative procedure. METHODS: 40 consecutive patients were prospectively randomized in 2 groups. 20 patients (Group A) had stepwise band-filling during 6 monthly ambulant visits. 20 patients (Group B) had a bolus-filling 4 weeks postoperatively and had the next follow-up after another 5 months. Weight loss, complications and procedural costs during follow-up were compared. RESULTS: Patients of both groups did not differ in age, gender or preoperative BMI. There was no significant difference postoperatively in excess weight lost (EWL) after 9 months. Postoperative complications did not differ significantly. By means of bolus-filling, a 60% and 53% reduction in outpatient clinical work was achieved within the 6 and 9 months, respectively. CONCLUSION: Postoperative management after gastric banding takes advantage of a single bolus-filling during the first postoperative 6 months due to sufficient weight loss, low complication rate but significant reduction of personal, financial and logistic efforts.

Necrotizing fasciitis with Clostridium perfringens after laparoscopic cholecystectomy.

Necrotizing fasciitis is a rapidly progressive infection of the fascia and subcutaneous tissues accompanied by a high mortality rate approaching 80% to 100%. Factors that predispose patients to this life-threatening complication include obesity, malnutrition, malignancy, chronic alcoholism, drug abuse, peripheral vascular disease, diabetes mellitus, and immunosuppressive therapy. The pathomechanisms for the development of this rare disease still remain unclear. We report a case of necrotizing fasciitis with Clostridium perfringens after laparoscopic cholecystectomy. The patient left the hospital 5 months after admission. Early recognition based on clinical signs (pain, asymmetric abdominal thickening, crepitus) and computed tomography scanning (gas dissection along fascial planes), in conjunction with prompt, aggressive surgical therapy and debridement of all devitalized tissue, high-dose antibiotic therapy, and therapy at the intensive care unit, appears to afford patients the best chance of survival.

Quality of life after cardiac surgery in the elderly.

BACKGROUND: Cardiac surgery in the elderly is performed with increasing frequency. Beside low mortality an evident gain in quality of life is the most important aim of therapy. To investigate the medium term outcome of cardiac surgery, we evaluated patients over 75 years of age who were operated on within a 1.5-year period. METHODS: Between 01/98 and 06/99, 124 patients (76 male, 48 female), mean age of 76.6 (range 75-86) years were operated on. Eighty-four per cent had isolated coronary or valve procedures and 16% had combined procedures. Pre- and postoperative NYHA classification, follow-up period, perioperative mortality and the subjective satisfaction were recorded. RESULTS: Total perioperative mortality was 6.4%. After a mean follow-up time of 15.2 (range 6-24) months, patient satisfaction with the operative results was excellent in 73%, good in 26% and low (unsatisfied) in 1%. CONCLUSIONS: Cardiac surgery in the elderly can be performed with an acceptable morbidity and mortality. The fact that 99.1% of the patients are satisfied with their operation and the dramatic improvement in functional status (96.5% NYHA I and II) justify cardiac surgery in this age.

Is a routine liquid contrast swallow following laparoscopic gastric banding mandatory?

BACKGROUND: The authors assess the value of liquid contrast medium swallow as a method to detect postoperative complications after laparoscopic adjustable gastric banding (LAGB) for the treatment of morbid obesity. METHODS: From January 1996 to January 2001, 350 morbidity obese patients (295 women, 55 men) underwent a LAGB operation. All data were prospectively collected in a computerized databank. All patients underwent a jopomidol swallow (JS) study in the early postoperative phase to exclude perforation of the esophagus or stomach, which is one of the most serious complications occurring after the LAGB operation. Furthermore, the JS was performed to confirm band position and to exclude early pouch dilatation. RESULTS: Out of the 350 LAGB operations, 6(1.8%) early pouch dilatations and 4(1.2%) stomach perforations occurred. All early pouch dilatations were recognized on postoperative JS and immediately repaired laparoscopically. Of the perforations, one was recognized intraoperatively, and the other three were diagnosed postoperatively, either by contrast media extravasation on the JS (two patients) or by computer tomography. CONCLUSION: Presently, all patients undergo routine postoperative JS, which exposes them to radiation, causes patient discomfort, and entails additional costs of approximately 100 US$ per patient. Of the last 250 patients in our series, there have not been any cases of early pouch dilatation and since 1998 only one case of perforation has occurred, which could be easily suspected clinically. Therefore, we believe that in experienced centers, it is not necessary to perform routine postoperative contrast media studies and recommend JS only in cases of complicated postoperative courses.

Laparoscopic gastric banding in older patients.

HYPOTHESIS: Older patients experience the same benefits from a laparoscopic gastric banding (LGB) operation as younger patients. DESIGN: A case series of 320 morbidly obese and superobese patients who underwent LGB within a 46-month period. SETTING: University Hospital Innsbruck, General Surgical Department, Innsbruck, Austria. PATIENTS: A consecutive sample of 320 patients who met the criteria for a bariatric procedure and were aged 18 years or older. Patients were divided into the following 2 age groups: younger patients (group A, 18-49 years) and older patients (group B, > or =50 years). INTERVENTION: Laparoscopic gastric banding with an adjustable gastric band. MAIN OUTCOME MEASURES: Clinicopathologic features, including weight loss, complications, length of hospital stay, and operative times, were reviewed retrospectively, and a multivariate analysis was carried out. RESULTS: Of 320 patients, we identified 68 older patients (21.5%, group B). The mean postoperative follow-up period was 12 months (range, 6-28 months). The average preoperative weight was 127.8 kg (body mass index [calculated as weight in kilograms divided by the square of height in meters], 44.29). The average total weight loss was 4.3 kg per month for the first 3 months, reaching an average total of 31.0 kg after 1 year. The excess weight loss after 12 months was 68%. Complications requiring reoperation occurred in 10.3% of patients. Ninety-seven percent of the patients reported an improvement in their comorbid conditions. CONCLUSIONS: Older patients receive the same benefits from LGB as younger patients, with an acceptable postoperative complication rate. Presently, our upper age limit is 70 years.

A study of pain after laparoscopic gastric banding.

BACKGROUND: The introduction of the laparoscopic approach to bariatric surgery has brought similar advantages as those seen in general surgery. There have been no trials assessing postoperative pain after laparoscopic adjustable silicone gastric banding (LASGB). We compared prospectively postoperative pain and outcome in LASGB and laparoscopic cholecystectomy (LC), to determine if morbidly obese patients can expect the same benefits from a laparoscopic approach in gastric banding as those which are known for LC in non-obese and obese patients. METHODS: In a prospectively collected database of 80 patients undergoing LASGB, information including a survey assessing the postoperative pain, the amount of analgetic drugs used, operative reports, laboratory data, and follow-up data was collected. This was compared to an equal number of patients undergoing LC. Postoperatively, all patients received standardized pain medication of 150 mg tramadol per day. Pain was assessed twice on postoperative days 1-3 using a patient questionnaire. RESULTS: Patient characteristics and duration of hospital stay were similar in the two groups. Although there was no significant difference in type and intensity of pain experienced by the patients in either group, the gastric banding patients reported less postoperative pain overall than those in the LC group. CONCLUSION: The analyzed data show that LASGB offers the same advantages as other laparoscopic operations, in that it induces less pain and enables the patient to return quickly to normal activity and work. The advantage over the compared LC group may be due to higher patient motivation, but was not statistically significant.

Effects of adjustable gastric banding on altered gut neuropeptide levels in morbidly obese patients.

BACKGROUND: Patients with gastroesophageal reflux disease (GERD) have alterations of gut neuropeptides, such as neurotensin (N) and motilin (M), which are resolved following antireflux surgery. Obesity is associated with GERD. Since the adjustable gastric band prevents gastroesophageal reflux in morbidly obese patients, this study was performed to investigate plasma levels of N and M before and after adjustable gastric banding (AGB). METHODS: 47 morbidly obese patients were operated laparoscopically using the Swedish AGB. Pre- and postoperatively basal plasma levels of N and M were investigated. Symptoms such as heartburn, regurgitation and dysphagia were documented, and esophageal manometry as well as 24-hour pH-monitoring were performed pre- and postoperatively. 11 non-obese, asymptomatic, age-matched volunteers served as controls. RESULTS: After a median postoperative follow-up period of 268 days, a significant weight reduction was observed. Preoperatively, 14 patients suffered from reflux symptoms. An insufficient lower esophageal sphincter (LES) was found in 8 patients, and 2 patients had impaired esophageal body motility. Pathologic pH-testing was found in 6 patients. Postoperatively, reflux symptoms were present in 4 patients; LES findings and pH-testing were normalized in all patients. However, there was significant impairment of esophageal peristalsis. Preoperatively, levels of N were significantly decreased and levels of M increased compared with control subjects. Postoperatively, there was a significant increase of N and levels of M were normalized. Alterations in gut neuropeptides did not correlate with reflux symptoms, impaired gastroesophageal motility, age, gender or BMI. CONCLUSION: Morbid obesity alters gut neuropeptides, which are resolved by AGB. This may be caused by reduction of hypercaloric nutrition postoperatively rather than by improvement of gastroesophageal reflux.

[Intestinal invagination due to endometriosis of the terminal ileum]. / Darminvagination durch Endometriose des terminalen Ileums.

HISTORY AND CLINICAL FINDINGS: A 39 year old female patient presented with nausea and crampy abdominal pain in the right lower quadrant. INVESTIGATIONS: Physical examination showed a markedly distended abdomen with a diffuse pain, punctum maximum in the right lower part of the abdomen and reduced peristalsis. Plain abdominal x-rays revealed slightly dilated loops of small bowel with air-fluid levels. Abdominal ultrasound revealed thickening of the bowel wall of the distal ileum and some free fluid. To exclude Crohn's disease, Sellink-computer tomography was performed, which also showed thickening of the wall of the terminal ileum and dilated bowel loops proximal to the underlying stenosis. DIAGNOSIS, TREATMENT AND COURSE: Intraoperatively, the terminal ileum was thickened by scar tissue and subtotally invaginated. Histologic investigation of the resected specimen showed submucosal endometriosis. CONCLUSION: Endometriosis of the small bowel should be considered carefully in the differential diagnosis of female patients of reproductive age who suffer from symptoms of ileus, dysmenorrhea and sterility.