Appendiceal knotting causing small bowel strangulation.

Small bowel obstruction is a common cause of an emergency admission in the surgical wards. Acute appendicitis presenting with small bowel obstruction due to appendiceal knotting is a very rare and unsuspected condition in an emergency scenario. We report a case of acute small bowel obstruction in a 26-year-old male who, on exploration was found to have small bowel strangulation due to appendiceal knotting. Though rare, the possibilities of such a diagnosis should be kept in mind in patients with small bowel obstruction with no known identifiable etiology.

A pilot study of Foley's catheter balloon for prevention of intrauterine adhesions following breach of uterine cavity in complex myoma surgery.

PURPOSE: During abdominal myomectomy for removal of multiple fibroids, the uterine cavity may be breached. Repair of the breach is associated with a risk of development of intrauterine adhesions. We conducted a pilot study to evaluate the effectiveness of temporary placement of a Foley's catheter balloon inflated with 30 ml normal saline into uterine cavity at the end of surgery to prevent this complication. METHODS: Retrospective cohort study. When the uterine cavity was breached during open myomectomy, it was repaired with a No. 2-0 vicryl suture. A Foley catheter balloon was inserted into the uterine cavity at the end of the procedure, and the balloon distended with 30 ml of normal saline. The balloon was removed on the fourth post-operative day. Follow-up hysteroscopy was performed after 6 months. RESULTS: At the time of follow-up hysteroscopy 6 months after the myomectomy, we found no intrauterine adhesions in 16 consecutive women treated with balloon, compared to 3 out of 10 (30 %) historical controls where the balloon was not used. CONCLUSION: A Foley catheter balloon inserted into the uterine cavity following breach and repair of the uterine cavity at open myomectomy appears to prevent the formation of intrauterine adhesions.

Refusal of blood transfusion by Jehovah's Witness women: a survey of current management in obstetric and gynaecological practice in the U.K.

BACKGROUND: Refusal of blood transfusion by Jehovah's Witness (JW) women poses potential problems for obstetrics worldwide as haemorrhage remains a major cause of maternal morbidity and mortality. There is a general consensus that morbidity and mortality rates in association with childbirth and gynaecological interventions are higher in these women than in the general population. We conducted a postal questionnaire survey of current practice among U.K. consultant obstetricians and gynaecologists to establish the practices that could contribute to poor outcomes in these women. MATERIALS AND METHODS: The main variables of interest were: use of a multi-disciplinary approach; the acceptable minimum haemoglobin (Hb) concentration before vaginal delivery and abdominal hysterectomy as low to medium risk scenarios and open myomectomy as a high risk scenario for haemorrhage; Hb concentration thresholds for iron supplementation; and the use of oral iron, intravenous iron, erythropoietin and cell salvage as potential management tools. RESULTS: The response rate was 28%. Sixty percent of gynaecologists and 85% of obstetricians reported having a protocol for the management of JW women. Forty-six percent of consultants adopt a multi-disciplinary approach which include anaesthetists and haematologists. A Hb concentration of >11-12 g/dL is considered the minimum acceptable level by a majority (47%) prior to normal delivery and by 42% of gynaecologists prior to abdominal hysterectomy. For open myomectomy 28% of gynaecologists prefer a minimum level of 11-12 g/dL but a further 31% of gynaecologists prefer a minimum level of 12-13 g/dL. DISCUSSION: A small but substantial proportion of consultants do not have protocols, operate on JW women with low Hb concentrations, do not use a lower Hb concentration threshold for supplementation, and do not adopt a multi-disciplinary approach, all of which could contribute to the reported poor outcomes in these women.

MR imaging evaluation of fibroid clearance following open myomectomy for massive/multiple symptomatic fibroids.

PURPOSE: To evaluate the technical success of total fibroid clearance at open myomectomy for massive and/or multiple symptomatic fibroids using MR imaging (MRI) as the imaging modality. METHODS: The study group comprised 27 women [mean age 37.4 ± 6.9 years (range 27-53)] who underwent open myomectomy for the treatment of massive/multiple symptomatic fibroids at our institution between January 2009 and April 2010. Myomectomy was performed with the intention of achieving complete fibroid clearance. Pre- and postmyomectomy MRI was performed to assess changes in uterine volume and fibroid burden. Periprocedural data (including blood loss and complications) and relief of clinical symptoms at follow-up were also recorded. RESULTS: The mean time to MRI and clinical follow-up was 10 months (range 6-15 months). The mean uterine volume premyomectomy was 795 ± 580 cc and postmyomectomy was 123 ± 70 cc (p < 0.001). The mean percentage reduction in uterine volume was 80.3 % (range 43.0-98.1 %). Of the 10/27 (37.0 %) women with residual fibroids at follow-up: 7 patients had fibroids measuring up to 1 cc in volume, 3 patients had fibroids measuring up to 6 cc. Postoperative adnexal seromas were observed in 6/27 (22.2 %) patients. The clinical success rates of myomectomy amongst the 22/27 (81 %) responders were: 73 % for menorrhagia, 64 % for pain, and 36-64 % for mass-related symptoms. CONCLUSIONS: Using MRI, we have confirmed that open myomectomy can achieve total or near-total fibroid clearance in the majority of patients with massive and/or multiple fibroids.

Acute complications of fibroids.

Although fibroids constitute the most common tumour in women of reproductive age, it is remarkable how very rarely they cause acute complications. However, when they do occur, the acute complications can cause significant morbidity (very occasionally, mortality), profoundly affecting a woman's quality of life. The complications include thrombo-embolism, acute torsion of subserosal pedunculated leiomyomata, acute urinary retention and renal failure, acute pain caused by red degeneration during pregnancy, acute vaginal or intra-peritoneal haemorrhage, mesenteric vein thrombosis and intestinal gangrene. The obstetrician will be most familiar with red degeneration and acute urinary retention, both of which tend to occur in association with pregnancy. It is difficult to quote an incidence rate for these acute complications as they are rare, and most are reported as cases or case series in the literature. The majority (except red degeneration, acute urinary retention and thrombo-embolism) presents as an acute abdomen and requires urgent exploratory surgery. The differential diagnosis would include twisted adnexa, ruptured ectopic pregnancy, haemorrhagic corpus luteum or follicular cyst, whilst that of the pelvic mass would be ovarian or endometrial carcinoma, uterine sarcoma or leiomyoma and, rarely, ovarian fibroma. Deep vein thrombosis is usually due to pelvic venous compression, and while some have advocated that its occurrence in association with a fibroid mass should be an absolute indication for hysterectomy, sophisticated use of radiological adjuncts at surgery, such as 'umbrellas' and haematological support with appropriate anticoagulation, could enable uterine-preserving surgery. The diagnosis of fibroids as a cause of acute urinary retention should be one of exclusion. The treatment of the acute fibroid in pregnancy is of course conservative, definitive treatment being postponed until postpartum.

Clinical presentation of fibroids.

Uterine fibroids, the most common tumours in women of reproductive age, are asymptomatic in at least 50% of afflicted women. However, in other women, they cause significant morbidity and affect quality of life. Clinically, they present with a variety of symptoms: menstrual disturbances including menorrhagia, dysmenorrhoea and intermenstrual bleeding; pelvic pain unrelated to menstruation; and pressure symptoms such as a sensation of bloatedness, increased urinary frequency and bowel disturbance. In addition, they may compromise reproductive function, possibly contributing to subfertility, early pregnancy loss and later pregnancy complications such as pain, preterm labour, malpresentations, increased need for caesarean section, and postpartum haemorrhage. Large fibroids may distend the abdomen, which may be aesthetically displeasing to many women. Abnormal bleeding occurs in 30% of symptomatic women, and abnormal bleeding, bloating and pelvic discomfort due to mass effect constitute the most common symptoms. The incidence of fibroids is highest in Black women, who tend to have multiple and larger fibroids, and more symptomatic fibroids at the time of diagnosis. The prevalence of clinically significant myomas peaks in the perimenopausal years and declines after the menopause. It is not known why some fibroids are symptomatic while others are quiescent. The size, number and location of fibroids undoubtedly determine their clinical behaviour, but research has yet to correlate these parameters with clinical presentation of the fibroids.