Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis.

BACKGROUND: Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA. OBJECTIVE: The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a single tertiary care IBD center. PATIENTS: All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified. MAIN OUTCOME MEASURES: The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks. RESULTS: The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05). LIMITATIONS: This study was limited by its retrospective design and evolving electronic medical charts system. CONCLUSIONS: The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693. LENTO Y CONSTANTE GANA LA CARRERA UN CASO SLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA: ANTECEDENTES:Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal.OBJETIVO:El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino.PACIENTES:Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas.RESULTADOS:La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución.CONCLUSIONES:La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.

Abnormal menstruation after radical trachelectomy and its effects on fertility.

AIM: To evaluate and identify the risk factors for abnormal menstruation after radical trachelectomy. METHODS: This study included 58 patients who underwent radical trachelectomy at our hospital between April 2005 and January 2018. Patients were divided into groups of those with no change in postoperative menstruation (regular [R] group; n = 46) and those with abnormal menstruation such as amenorrhea or hypomenorrhea (irregular [I] group; n = 12). The perioperative characteristics and fertility of the groups were compared retrospectively. The data were statistically analyzed using Student's t-test, Fisher's exact test and Mann-Whitney U test for univariate analysis and logistic regression analysis for multivariate analysis, with the level of statistical significance set at P < 0.05. RESULTS: Based on Federation of Gynecology and Obstetrics staging, 54 patients had stage IB1, 2 had stage IB2 and 2 had stage IIA1 cervical cancer. Eight patients received neoadjuvant chemotherapy. Pretreatment tumor size, residual uterine cavity length and neoadjuvant and postoperative chemotherapy use were not significantly different between the groups. Abnormal menstruation was significantly more common in patients with postoperative pelvic infection (R group, 13.0%; I group, 58.3%) and cervical stenosis (R group, 15.2%; I group, 58.3%). CONCLUSION: To maintain healthy menstruation even after radical trachelectomy, it is important to prevent postoperative pelvic infection and cervical stenosis.

Contrast radiography before diverting stoma closure in rectal cancer is not necessary on a routine basis. / El estudio radiológico con contraste antes del cierre del estoma derivativo en el cáncer de recto no es necesario de forma rutinaria.

INTRODUCTION: Diverting stomata are recommended in patients with low anterior resection and risk factors in order to reduce the severity of anastomotic leaks. Usually, a radiology study is performed prior to the closure of the stoma to detect subclinical leaks. The aim of the present study is to assess the clinical utility of the radiology study. METHODS: A prospective cohort study of patients undergoing anterior rectal resection for rectal cancer and those who underwent stoma closure without contrast enema. This study was carried out after a retrospective review of radiology study results prior to the closure of the stoma in patients operated from 2007 to 2011. RESULTS: Eighty-six patients met the study criteria. Thirteen patients (15.1%) presented pelvic sepsis. Contrast enema before stoma closure was pathological in 8 patients (9.3%). Five out of the 13 patients with pelvic sepsis had a pathological radiological study, compared to only 3 out of the 73 patients without intra-abdominal complications after rectal resection (38.5% vs. 4.1%; P=.001). Based on these results, we conducted a prospective study omitting the contrast enema in patients with no postoperative complications. Thirty-eight patients had their stoma closed without a prior radiology study. None of the patients presented pelvic sepsis. CONCLUSIONS: Radiology studies of the colorectal anastomosis before reconstruction can safely be omitted in patients without pelvic sepsis after the previous rectal resection.

Influence of follicular fluid and cumulus cells on oocyte quality: clinical implications.

An equilibrium needs to be established by the cellular and acellular components of the ovarian follicle if developmental competence is to be acquired by the oocyte. Both cumulus cells (CCs) and follicular fluid (FF) are critical determinants for oocyte quality. Understanding how CCs and FF influence oocyte quality in the presence of deleterious systemic or pelvic conditions may impact clinical decisions in the course of managing infertility. Given that the functional integrities of FF and CCs are susceptible to concurrent pathological conditions, it is important to understand how pathophysiological factors influence natural fertility and the outcomes of pregnancy arising from the use of assisted reproduction technologies (ARTs). Accordingly, this review discusses the roles of CCs and FF in ensuring oocyte competence and present new insights on pathological conditions that may interfere with oocyte quality by altering the intrafollicular environment.

Coccidioidomycosis Presented as a Pelvic Mass in an Otherwise Healthy Female.

We present a case of a 32 year old female with a past medical history of hypertension who presented with several years of chronic back pain and was ultimately diagnosed with isolated pelvic coccidioidomycosis. She was initially seen by gynecologic oncology for assessment of possible metastatic cancer by image study, but a cytopathologic diagnosis of coccidioidomycosis lead to a cancellation of the planned surgery and extensive antifungal treatment managed by the infectious disease team. She had no known previous pulmonary disease or immunodeficiency. Pelvic coccidioidomycosis without known pulmonary disease is very rare, and disseminated infection typically only occurs in those who are severely immunocompromised. Our case presented with several years of back pain and a pelvic mass mistaken for possible malignancy by image study.

Quiste gigante de próstata / Giant cyst of the prostate

No disponible

Diagnostic value of diffusion-weighted magnetic resonance imaging in pelvic abscesses.

OBJECTIVE: The objective of this study was to prospectively assess the added value of gadolinium-enhanced and diffusion-weighted (DWI) magnetic resonance imaging (MRI) to pelvic T2-weighted MRI for diagnosis of deep pelvic abscesses. METHODS: Twenty-nine patients with suspected abscess and a control group of 43 patients underwent T2-weighted, gadolinium-enhanced, T1-weighted and DWI magnetic resonance sequences. Three readers (R1, R2, R3) scored likelihood of abscess on standard MRI, standard MRI + gadolinium, and standard MRI + DWI. RESULTS: Twenty-nine patients had 36 abscesses. On standard MRI, R1 achieved area under the receiver operating characteristic (ROC) curve (AUC) of 0.97, sensitivity 92%, and specificity 100%. For R2, these figures were 0.87, 81%, and 100%, and for R3, these were 0.85, 83%, and 79%. After gadolinium, R2 improved AUC to 0.97 (P = 0.005), and R3 to 0.95 (P = 0.006). Standard MRI + DWI yielded improved AUC for all readers (P = 0.15, 0.001, and 0.001 for R1, R2, R3, respectively). CONCLUSIONS: Addition of gadolinium or DWI to T2-weighted MRI improves performances for the diagnosis of deep pelvic abscess. Diffusion-weighted imaging may replace gadolinium.

Primary pelvic hydatic cyst mimicking ovarian carcinoma.

Hydatic cyst is an illness that appears in consequence of the cystic form of small strap-shaped worm Echinococcus granulosis. Frequently, cysts exist in the lungs and liver. Peritoneal involvement is rare, and generally occurs as a result of second inoculation from rupture of a liver-located hydatic cyst. Primary ovarian hydatic cyst is very rare. A 56-year-old female patient was admitted to Emergency Service with the complaint of stomachache and swollen abdomen. From ultrasonographic examination, a right ovarian 52 × 45-mm heterogeneous semi-solid cystic mass and right hydronephrosis were detected. As a result of the tomographic examination, the right ovarian growth was judged to be a 60 × 45-mm lobule contoured, septal, heterogeneously cystic mass (ovarian carcinoma). Depending on these indicators and with the diagnosis of ovarian carcinoma, laparotomy was planned. During the observation, a mass that compressed on the right ureter and dilatation in the right ureter were determined. The mass was approximately 6 cm long and smoothly contoured, including widespread adhesions, and also obliteration of the pouch of Douglas. The mass was excised and total abdominal hysterectomy and bilateral salpingo-oopherectomy performed. After a pathological examination, hydatid cyst was diagnosed. Although pointing at the issue of the distinctive diagnosis of pelvic and peritoneal mass, it should be realized that the existence of primary peritoneal and pelvic involvement of the hydatic cyst is generally a result of the second inoculation, and is also more common in regions in which Echinococcus granulosa is endemic and livestock production is prevalent.

Laparoscopic removal of infected mesh colposacropexy.

Mesh colposacropexy is a procedure performed for massive genital prolapse with a good success rate and a low incidence of intraoperative and postoperative complications. Mesh infection is an uncommon but feared complication that requires mesh removal which has hitherto been done only transvaginally or through laparotomy. We are reporting three cases of infected mesh colposacropexies which were successfully removed using the laparoscopic technique.

[Pelvic and abdominal actinomycosis presenting as a parietal mass]. / Actinomycose abdominopelvienne révélée par des abcès pariétaux.

INTRODUCTION: Actinomycosis is a rare disease. It has a highly varied clinical picture and may simulate genital or gastrointestinal neoplasms. CASE: This 45-year-old woman was referred for suspected ovarian cancer, with secondary lesions of the liver and pelvic wall. Pelvic actinomycosis was first suggested by the presence of an intrauterine device (IUD), which had been in place for several years without any follow-up. The final diagnosis was based upon histological examination of a biopsy sample of the parietal mass. COMMENTS: The association of apparent pelvic tumors with infection and inflammation together with the presence of an IUD must suggest genital actinomycosis and lead to the rejection of any immediate surgical resection. The diagnosis is usually histological, with samples obtained either surgically or by percutaneous stereotactic biopsy. The treatment is essentially medical and consists of long-term antibiotics (penicillin). The prognosis is usually good.

Easy drainage of presacral abscess.

Presacral region is one of the difficult regions for drainage of abscess as the approaches described for this carry a lot of morbidities. Transpedicular approach is described for the drainage of presacral abscess. Further, tuberculous abscess as a cause of cauda equina syndrome is reported. Patient had complete neurological recovery within weeks of drainage of abscess. Transpedicular drainage of presacral abscess is a safer option for recently developed neurological deficit. Late presentation may need anterior approach, which is associated with increased morbidity.

[Two cases of pelviperitonitis caused by Streptococcus pneumoniae].

Streptococcus pneumoniae is known to be a common component of the indigenous flora of the oropharynx. Pneumococci are most notable for their role in causing otitis, sinusitis, meningitis, and inflammation of the respiratory tract. Meanwhile, Streptococcus pneumoniae demonstrate a wide potential of virulence and they have been isolated from various clinical specimens, for example, in arthritis. This paper describes two cases of pneumococci being found in pelviperitonitis. A Streptococcus pneumoniae strain was found to be sensitive to ampicillin, cefazolin, ceftriaxone, erythromycin, oxacillin, trimethyl/sulfa.

Pelvic actinomycosis: still a cause for concern.

Three cases of pelvic actinomycosis, which presented over a short period of time, are described. In all three cases the diagnosis was only considered following laparotomy, although there were characteristic diagnostic clues at presentation. In two cases imaging of the pelvis by ultrasound and computed tomography was unhelpful in distinguishing the condition from pelvic neoplasia.