Intra- and interobserver reproducibility of transvaginal ultrasound for the detection and measurement of endometriotic lesions of the bowel.

INTRODUCTION: The number and invasion depth of endometriotic bowel lesions, total length of bowel affected by endometriosis, lesion-to-anal verge distance, and extent of pouch of Douglas obliteration are important factors in preoperatively determining risk and complexity of endometriosis surgery. The intra- and interobserver reproducibility of transvaginal ultrasound in the evaluation of many of these parameters has not yet been investigated. Our study aimed to assess the intra- and interobserver reproducibility of transvaginal ultrasound between an experienced and less experienced examiner for all of these parameters. MATERIAL AND METHODS: This prospective observational cross-sectional study was conducted between July 2019 and November 2020. Fifty consecutive premenopausal women who underwent transvaginal ultrasound examination in our clinic for the first time, were examined by the same two operators during the same attendance. Outcomes of interest were the inter-rater reproducibility of transvaginal ultrasound for detecting the presence, number, depth and size of bowel endometriotic nodules, lesion-to-anal-verge distance, total length of bowel affected, and pouch of Douglas obliteration. The intraobserver reproducibility was assessed for the continuous parameters. Cohen's kappa (κ) statistic, Cohen's weighted kappa (κ), proportions of agreement, intraclass correlation coefficient (ICC) and Bland-Altman limits of agreement were used to assess the reproducibility of the parameters. RESULTS: The inter-rater agreement and reliability were very good for identifying bowel endometriosis, the number and invasion depth of bowel nodules, determining whether the maximum nodule length was <3 cm, and lesion-to-anal-verge distance <8 cm (proportion of agreement 0.92, 0.94, 0.97, 0.94, 0.96; κ 0.92, 0.91, 0.92, 0.82, 0.89). The inter-rater agreement and reliability were good for assessing pouch of Douglas obliteration (proportion of agreement 0.86, κ 0.80). The intra-rater reliability for the mean nodule diameter (ICC 0.93 and 0.97) and total length of bowel affected (ICC 0.94 and 0.91) were excellent for operators A and B, respectively. The inter-rater reliability for the mean nodule diameter was good (ICC 0.80), and moderate for the total length of bowel affected (ICC 0.70). The Bland-Altman limits of agreement demonstrated clinically acceptable ranges for these two parameters. CONCLUSIONS: This study demonstrated a high intra- and inter-rater reproducibility of transvaginal ultrasound in the diagnosis of bowel endometriosis and measurement of its various components.

Clinical, endoscopic and histological profile of colorectal cancers seen on colonoscopy in Kano, North-Western Nigeria.

BACKGROUND: Colorectal cancer (CRC) is the most prevalent gastrointestinal (GI) cancer. With 5% risk of developing CRC in life, it became the third leading cause of cancer death in developed nations. In Nigeria, it is the most common GI cancer. However, there are limited data on CRC in the study area (North-Western part of Nigeria). The aim of this study was to identify the clinical, endoscopic and histological profile of CRC seen on colonoscopy. METHODOLOGY: This was a retrospective descriptive study where colonoscopic and histological records of suspected CRC in the study centre between January 2008 to December 2017 were evaluated. RESULTS: Records of 135 patients were reviewed, and males constituted 63.7%. The mean age was 46.61 ± 16.80 years, with 30-39 years as a modal group. Common presentations were diarrhoea (86.7%) and bleeding per rectum (68.9%). Areas affected were rectosigmoid colon (63%), ascending colon (14.1%), descending colon (8.9%), transverse colon (7.4%) and anal canal (6.7%). Histologically, adenocarcinoma was reported in 57.8%, mucinous adenocarcinoma in 8.1% and signet ring cell adenocarcinoma in 3.7%. Tubular and villous adenomas were 3% each. Others were carcinoid tumours (1.5%), metastatic adenocarcinoma, squamous cell carcinoma, basal cell carcinoma, GI stromal tumour, inflammatory myofibroblastic tumour, angiosarcoma and adenoid cyst carcinoma reported in 0.7% each. CONCLUSION: Majority of the patients with CRC were in their young age. The most common presentations were diarrhoea, weight loss and anaemia. The most common site of affectation was in the left colon, while the most common histological finding was adenocarcinoma.

Laparoscopic Rectosigmoid Colon Vaginoplasty in Male-to-Female Transsexuals: Experience in Japan.

Intestinal vaginoplasty has several advantageous features, such as scarless surgery, low incidence of contraction of the reconstructed vagina, maintenance of vaginal depth, spontaneous mucus production, and a low rate of complications. Therefore, this technique is becoming popular in many countries. Following the global trend, the demand for intestinal vaginoplasty for transsexuals is also increasing in Japan. However, there are few reports on intestinal vaginoplasty in Japan. In this study, we examined the safety and effectiveness of rectosigmoid colon vaginoplasty in the Japanese population. We retrospectively surveyed 18 male-to-female transsexuals who underwent laparoscopic rectosigmoid colon vaginoplasty at the Okayama University Hospital Gender Center between October 2012 and December 2017. One patient had developed an anastomotic leak and 2 patients experienced vaginal prolapse, which needed revision surgery. Both adverse outcomes were comparable with those from previous studies. The anastomotic leak was managed adequately with conservative treatment. To avoid vaginal prolapse, it is important to decide the length of the rectosigmoid segment so that a pull on it does not cause it to become lax, while excessive stress on the feeder vessels is avoided. Based on our study, we concluded that rectosigmoid vaginoplasty was a reliable technique in the Japanese population.

A Rare Case of Complete Perforation of Endometrial Tissue Through the Mucosa of the Sigmoid Colon.

Endometriosis is a disease that causes endometrial tissues to proliferate outside of the uterus. The condition is often attributed to estrogen imbalance and can lead to severe inflammation and bleeding, where it is believed that 10% of female patients experience this illness. Endometrial growth can occur in the ovaries, fallopian tubes, stomach, and gastrointestinal tract. Twelve percent of endometriosis cases can be seen in the intestines, with the rectosigmoid colon accounting for 72% of these cases. Patients with intestinal endometriosis may present with moderate symptoms, such as constipation, but they may experience more serious complications as well such as intestinal bleeding. Although the presence of endometrial tissue in the colon is already a rare phenomenon, it is even rarer for endometrial growth to perforate the entire mucosa of the sigmoid colon. A study in 2010 reported that only 21 of such cases have occurred since 1931. The patient in this case report had a gene (MUTYH) mutation that put her at risk for colorectal cancer, and she was ultimately treated with segmental resection of the sigmoid colon. The final pathology of the specimen revealed that the patient's lesion was endometrial growth. In this case report, we present a rare finding of endometrial tissue perforating through a patient's intestinal lumen, which was successfully treated with surgical intervention.

An Unusual, Delayed Presentation of a Migrated Intrauterine Contraceptive Device Into the Rectosigmoid Colon.

The current literature suggests that serious complications after intrauterine contraceptive device (IUCD) insertion are rare. We present a rare case of a migrated IUCD into the rectosigmoid colon. A 33-year-old woman (parity one) presented to the emergency department with a three-day history of flank pain, upper urinary tract infection symptoms, and a low-grade fever. Differentials initially included renal colic or pyelonephritis. However, subsequent computed tomography of the kidneys, ureters, and bladder (CT-KUB) and magnetic resonance imaging of the pelvis (MRI-pelvis) showed a migrated IUCD posterior to the uterine body, with both ends closely abutting onto the adjacent proximal rectum. During further history-taking, she reported a past surgical history of an emergency caesarean section five years ago and the insertion of a copper-IUCD six weeks postnatally. She was subsequently referred to the gynaecologists. In view of the involvement of the bowels, the colorectal surgeons were consulted, and the patient was managed by a multidisciplinary team. The patient subsequently underwent diagnostic hysteroscopy, flexible sigmoidoscopy, diagnostic laparoscopy, removal of impacted IUCD, and repair of the rectum. Intraoperatively, her hysteroscopy noted a normal uterus with an intact cavity. Flexible sigmoidoscopy noted the horizontal arm of the IUCD abutting into the lumen of the rectosigmoid region; however, attempted removal with traction was unsuccessful. A partial rectotomy was done eventually to remove the IUCD. Migration of an IUCD is rare, with uterine perforation rates ranging from 0.04% to 0.2%. Albeit a rare complication, this case highlights the need for clinicians to be cognizant of complications arising from IUCD insertion, as symptoms are often non-specific and mild. This case also highlights the importance of a multidisciplinary discussion in the management of a migrated IUCD, which may include gynaecologists, colorectal surgeons, radiologists, and more. Many innovative ways were also discussed regarding the assessment of it, which includes preoperative imaging or endoscopic evaluation. Novel methods of removal of migrated IUCD in the rectosigmoid colon have also been proposed, including manual traction, proctoscopy, rigid sigmoidoscopy, and removal via a snare. They provide an alternative to the traditional diagnostic laparoscopy or laparotomy, thus reducing the need for general anaesthesia or operative intervention. Looking forward, long-term studies can be done to evaluate the need for intervention for asymptomatic patients where the risk of surgery may outweigh the benefits.

Rectosigmoid endometriosis: Diagnostic pitfalls and management - A case report.

Endometriosis constitutes a benign condition, occurring in 10%-12% of menstruating women. Bowel involvement is estimated to occur in 5%-12% with the rectosigmoid region involved in up to 90% of these cases. We present the case of a 45-year-old Caucasian female patient with rectosigmoid endometriosis.

Cervical Stump Cancer Treated With Radiotherapy Using Computed Tomography-Guided Brachytherapy.

Cervical stump cancer, which arises in the remaining uterine cervix of a woman with a history of supravaginal hysterectomy, accounts for 1.6-4.4% of all cervical cancers. The close proximity of the rectosigmoid colon to the primary tumor, which is due to the absence of the uterine corpus, should be considered carefully in the treatment planning of brachytherapy. Although three-dimensional image-guided brachytherapy (3D-IGBT) is used widely to treat cervical cancer in those with an intact uterine corpus, the safety and efficacy of 3D-IGBT for cervical stump cancer remains unclear. Here, we report a case of cervical stump cancer (T3bN1M0) treated successfully with definitive radiotherapy, which combined external beam radiotherapy and computed tomography (CT)-based IGBT. By applying the dose prescription concept used for definitive brachytherapy of cervical cancer with an intact uterine corpus, IGBT achieved satisfactory dose conformity to the tumor while sparing the adjacent rectosigmoid colon. This led to local tumor control for three years and eight months, with no late adverse effects. This case suggests that radiotherapy using CT-based IGBT is a safe and effective treatment for cervical stump cancer.

Sonographer-acquired ultrasound protocol for deep endometriosis.

Endovaginal sonographic imaging has been shown to reliably identify pelvic endometriosis, but most United States imaging practices do not adequately assess locations and features of endometriosis beyond ovarian endometrioma. In this article, we propose a protocol for sonographer-acquired images and maneuvers to be interpreted subsequently by sonologists (radiologists or gynecologists). The purpose is to improve the sensitivity of endovaginal sonography for the detection of endometriosis in imaging practices that involve the non-physician sonographer as part of their workflow.

Successful treatment of basaloid squamous cell carcinoma in the rectosigmoid colon: A case report and review of literature.

BACKGROUND: Compared with colorectal adenocarcinoma, basaloid squamous cell carcinomas (BSCCs) arising in the colorectum are rare and have very poor prognosis. To date, only nine cases have been reported. Most BSCCs are extensively involved in metastasis to the lymph node, liver, and lung at diagnosis. Despite many clinicians attempting to effectively treat BSCCs, therapeutic consensus has not been established due to lack of information. CASE SUMMARY: A 58-year-old woman presented with abdominal pain, diarrhea, fever, and hematochezia. She was referred from a department of gynecology and was diagnosed with a suspicious leiomyosarcoma of the rectum or a pedunculated myoma of the uterus. An exophytic growing mass at the right lateral wall of the rectum with an internal cystic portion and hemorrhage was observed on magnetic resonance imaging. The patient underwent low anterior resection and total hysterectomy with bilateral salphingo-oophorectomy. Histopathological findings revealed a cellular mass with a solid growth pattern and few glandular structures, many foci of intratumoral necrosis, and a palisading pattern. The pathologist diagnosed tumor as a BSCC, and the patient received chemotherapy with fluorouracil/leucovorin without radiotherapy. The patient is currently alive 8 years after the surgery with no manifestations of metastatic colon cancer. CONCLUSION: Our case suggest that curative resection and chemotherapy play important roles in improving survival, and radiotherapy may be an option to avoid radiation-associated enteritis.

How to deal with rectal lesions more than 15 cm from the anal verge through transanal endoscopic microsurgery.

BACKGROUND: The aim of this study is to assess postoperative morbidity and mortality in tumors with a proximal margin 15 cm or more from the anal verge operated with transanal endoscopic microsurgery (TEM). METHODS: This observational study of consecutive rectal tumor patients undergoing TEM was carried out from July 2004 to June 2017. We compared the results of rectal tumors at distances of ≥15 cm (group A) and <15 cm (group B) from the anal verge. RESULTS: During the study period 667 patients were included: 118 in group A and 549 in group B. In the comparative analysis there were no significant differences in morbidity (p = 0.23), mortality (p = 0.32) or free margin involvement (p = 0.545). Differences were observed in terms of lesion size (p < 0.001), surgical time (p < 0.001) and peritoneal cavity perforation, which were all increased in group A. CONCLUSION: TEM for lesions in the rectosigmoid junction is feasible and is not associated with higher morbidity or mortality.

Phlegmonous Proctitis: A Rare Entity of the Presentation of Proctitis.

Phlegmonous proctitis is a rare condition; it was first described in 1940. We report the case of an elderly woman who presented with acute severe lower abdominal pain, tenesmus, and fever. A computed tomography of the whole abdomen revealed a long segment of circumferential wall thickening of the rectum and rectosigmoid colon. Colonoscopy was done subsequently and showed marked edematous and erythematous rectal mucosa. When rectal tissue biopsy was performed, a large amount of pus came out at the biopsy site, which led to the diagnosis of phlegmonous proctitis.

Vaginal reconstruction with the modified rectosigmoid colon: surgical technique, long-term results and sexual outcomes.

Although vaginal reconstructions with intestinal segments require particularly complex surgical procedures, this technique has become popular with respect to fairly good functional and esthetic outcomes. This study describes cases of vaginal reconstruction performed using a modified rectosigmoid colon held in an ischemic state in order to reduce secretion and denervated in order to prevent defecation problems. Vaginal reconstructions with rectosigmoid colon were performed on 43 patients. In this retrospective study, 34 patients had Müllerian agenesis, while nine had undergone male to female sex reassignment surgery in which adequate vaginal depth had not been achieved. A rectosigmoid colon with its vascular pedicle was used and left in an ischemic state. All nerve structures within the pedicle were excised intraoperatively. Follow-up period was between 12 and 60 months. Partial necrosis occurred in one patient which was reconstructed with local flap. Hematoma developed beneath the skin incision in two cases, but resolved with conservative treatment. A good esthetic outcome was achieved in all cases. Sexual function was assessed using the Female Sexual Function Index (FSFI) in 15 patients. Fourteen out of 15 patients scored above 26.5 on this scale and were determined as having no sexual dysfunction (FSFI score ≥26.5). In conclusion, vaginal reconstruction with denervated rectosigmoid held in an ischemic state appears to be a reasonable option among several available reconstruction techniques.

Fish bone migration to the urinary bladder after rectosigmoid colon perforation.

Fish bones are the most common foreign objects leading to bowel perforation. Most cases are confined to the extraluminal space without penetration of an adjacent organ. However, abscess formation due to the perforation of the rectosigmoid colon by a fish bone can lead to the penetration of the urinary bladder and may subsequently cause the fish bone to migrate into the urinary bladder. In the presented case, a 42-year-old female was admitted for lower abdominal pain. The computed tomography (CT) demonstrated a 5 cm pelvic abscess containing a thin and curvilinear foreign body. After conservative management, the patient was discharged. After 1 mo, the subject developed a mechanical ileus. Surgery had to be delayed due to her hyperthyroidism. Migration of the foreign body to the urinary bladder was shown on additional CT. A Yellowish fish bone 3.5 cm in size was removed through intra-operative cystoscopy. The patient was discharged 8 d after the operation without any unexpected event.