Incisional endometriosis: an underappreciated diagnosis in general surgery.

BACKGROUND: Incisional endometriosis is a described dinical entity in the gynecologic literature, but it is not well recognized among general surgeons; only 32 cases have been reported in the general surgery literature. The preoperative diagnosis is often mistaken for a suture granuloma, lipoma, abscess, cyst, or incisional hernia. STUDY DESIGN: We performed a retrospective review of 10 cases of incisional endometriosis at our institution to determine which, if any, clinical factors would suggest the diagnosis preoperatively. All general surgery patients who had the diagnosis of endometriosis in their pathology specimens from January 1990 to December 1998 were reviewed. RESULTS: All 10 patients had previous cesarean sections through either a Pfannenstiel (n = 8) or a lower midline (n = 2) incision. Ages ranged from 27 to 41 years (mean 33.4 years). The most common presenting symptom was a slow-growing, painful lump in the lateral aspect of the Pfannenstiel incision. Two of the patients had a change in symptoms with their menstrual cycle. The duration of symptoms ranged from 2 months to 3 years. All patients underwent surgical excision. The size of the excised endometriomas ranged from 1.5 cm to 4.8 cm (mean 3.1 cm). CONCLUSIONS: Incisional endometriosis may be more common than previously recognized. In all cases it was found to occur in women with a history of cesarean section. Most patients presented with a painful, slow-growing lump at the lateral edge of their incision. Cyclic changes in pain and size of the mass with menses was elicited in only two of these patients, but this may be from a lack of awareness and questioning on the part of the physician. If the diagnosis is made preoperatively, additional diagnostic studies may be avoided. An awareness of this disease process on the part of general surgeons is necessary to guide preoperative evaluation and therapy appropriately.

The role of endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy in the management of choledocholithiasis.

Perioperative endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) offer the ability to remove common bile duct stones (CBDS) and still use the laparoscopic technique for cholecystectomy. The accuracy of predicting choledocholithiasis has been variable in several studies. The indications and complications of perioperative ERCP and ES with laparoscopic cholecystectomy (LC) are presented here. Between 6/1/90 and 11/11/93, 484 LC were performed at Santa Barbara Cottage Hospital. A total of 38 patients underwent perioperative ERCP; 33 patients underwent preoperative ERCP with 3/33 (9%) failing to cannulate the ampulla; 15 patients had choledocholithiasis; and 14/15 (93%) were cleared by ES. Fifteen patients had a normal CBD on ERCP. There were no deaths in this group of patients, seven of 38 (18%) had complications, including bleeding and post ERCP hyperamylasemia. Patients who had a normal CBD and underwent preoperative ERCP (9/15, 60%) had a history of gallstone pancreatitis or hyperamylasemia that was resolved or resolving before ERCP. Patients without stones on ERCP or cholangiogram (11/15, 73%) had a normal bilirubin (avg. 1.0 mg/dL; Range 0.4-2.3). Patients with choledocholithiasis (8/15, 53%) had a history of jaundice or elevated bilirubin before ERCP (avg. 2.59 mg/dL; range 0.2-9.3). ERCP with ES and laparoscopic cholecystectomy is a safe and effective method for the management of symptomatic cholelithiasis with choledocholithiasis. A history of gallstone pancreatitis or hyperamylasemia that is resolving or resolved in the absence of an elevated bilirubin does not require preoperative ERCP before LC with cholangiogram.

Injuries of the duodenum.

The records of 115 patients with a duodenal injury have been reviewed. The majority of the patients (83 percent) were treated with primary repair of the injury. Twelve patients underwent duodenal diverticulization. The mortality rate in all 115 patients was 12 percent, in 105 patients who survived more than 48 hours 4 percent, and in 26 patients with pancreaticoduodenal injury 15 percent. Vascular injury was the major cause of early death. Enteric perforations were present in 75 percent of the patients with sepsis. The majority of patients with associated pancreatic injury had primary repair and did not have pancreaticoduodenal complications. Duodenal fistula continues to be a serious postoperative complication. Primary repair with drainage is the preferred treatment. Gastrostomy and feeding jejunostomy are useful adjuncts. A more complex operation should be reserved for a highly select group of patients with severe duodenal injury.

Ruptured amebic liver abscess.

Fifteen cases of extrahepatic rupture of amebic liver abscess have been reviewed. Five patients had thoracic rupture and ten had intra-abdominal rupture. Celiotomies were performed in five patients, with a preoperative diagnosis of acute appendicitis with perforation in four patients and generalized peritonitis of unknown origin in one patient. All 15 patients were treated with amebicides, including three patients with documented free intraperitoneal perforation who were not treated surgically. Twelve patients recovered uneventfully. Two patients with thoracic rupture developed secondary bacterial complications and in one case of free intraperitoneal rupture, a mistaken diagnosis of ruptured pyogenic abscess was made. Amebicidal therapy was delayed for four days. The patient died of multisystem organ failure. Amebicidal therapy is effective in the treatment of both unruptured and extrahepatic rupture of amebic liver abscess. Surgery should be required only for secondary bacterial complications.