Abdominal wall endometriosis: A challenging iatrogenic disease.

INTRODUCTION AND IMPORTANCE: Abdominal wall endometriosis is a rare clinical condition associated with abdominal pain and psychologic disorders. It's pathophysiology remains unclear. Clinical history and imaging findings are necessary for the diagnosis. Its management is challenging, and requires close collaboration between gynaecologists and visceral surgeons specially in complex procedures. The aims of our study are to present risk factors, clinical presentation, imaging findings and management features. It was a retrospective descriptive study including fifteen patients presenting abdominal wall endometriosis. Data about age, medical history, imaging findings, surgical procedures and outcome are reported. CASES PRESENTATION: Fifteen women were included in our study. The most common symptom was cyclic abdominal pain. Twelve of them had history of caesarean section, and three had history of myomectomy. All patients underwent ultrasound and MRI. We performed surgical excision to all cases. One patient needed large excision with abdominoplasty procedure. CLINICAL DISCUSSION: Abdominal wall endometriosis is a rare clinical condition with unclear pathophysiology. It occurs frequently after gynaecologic or obstetric surgery. Most reported complaint was catamenial abdominal pain with abdominal wall mass. Ultrasonography, computed tomography and MRI are useful for diagnosis, specially to eliminate differential diagnoses. Abdominal wall endometriosis management is based on surgery. Excision goals are to remove the mass and to confirm histological diagnosis of parietal endometriosis. CONCLUSION: Parietal endometriosis is a rare and challenging condition with unclear pathophysiology. It requires specific management. This pathology will be encountered more frequently considering the increasing rate of caesarean section.

Cecal volvulus: A rare post-partum complication.

INTRODUCTION AND IMPORTANCE: Cecal volvulus is a rare clinical condition. It is characterized by axial twist of caecum, terminal ileum and the ascendant right colon around their mesenteric pedicles. The main pathophysiologic mechanism is cecal hyper mobility associated to precipitating factor such as colonic tumor, abdominal mass or pregnancy. Cecal volvulus during pregnancy was reported, but it remains exceptional during postpartum period. CLINICAL PRESENTATION: We report a case of cecal volvulus occurring in 37-year-old woman ten days after cesarean section delivery. She presented an acute abdominal pain associated to vomiting and nausea. X ray imaging and abdominal CT showed a large colonic obstruction, the caecum was dilated and located in the left hypochondrium. An open surgery was performed showing twisted bowels involving the caecum, the ileocecal junction and the right colon. There were necrotic areas on the colonic wall. Right hemicolectomy was performed with end to side ileo-colostomy. The evolution was marked by a serious septic shock causing patient's death. CLINICAL DISCUSSION: Cecal volvulus is a rare condition. Its suggested mechanism associates cecal hyper mobility to a precipitating factor. Increased uterine volume may explain cecal volvulus during pregnancy. In post-partum period, it may be explained by rapid uterine size variation. Cecal volvulus diagnosis is challenging. In fact, its symptoms can be confused with post operative ileus after cesarean section delivery. Delayed management leads to worst prognosis. CONCLUSION: Cecal volvulus during post-partum period is a rare condition, it may be serious in case of delayed diagnosis.

Pelvic actinomycosis: A confusing diagnosis.

INTRODUCTION AND IMPORTANCE: Actinomycosis is a rare chronic and suppurative infection caused by anerobic Gram Positive bacteria: actinomyces. Pelvic location is extremely rare, usually associated with history of IUD contraception and doesn't have specific signs. Pelvic actinomycosis diagnosis may be confused with pelvic gynecologic malignancies or abscess. We present a retrospective and descriptive study of twelve patients with pelvic actinomycosis diagnosed and managed in our department from January 2000 to December 2011. CASES PRESENTATION: The patients' mean age was 47 years. 75% of them had a history of IUD for a mean period of 8,44 years. Pelvic pain was the most common complaint. In four cases, pre-operative clinical presumption was tubo-ovarian abscess. Gynecologic malignancies were suspected in 8 patients. Pelvic actinomycosis management was based on surgery and long-term antibiotic. CLINICAL DISCUSSION: Pelvic actinomycosis is an extremely rare chronic infection, presenting 3% of human actinomycosis. Common clinical presentations include vaginal discharge, tubo-ovarian abscess and pelvic tumors mimicking gynecologic malignancies. It is difficult to diagnose. Association with IUD history was recognized. Management is based on surgery and long-term antibiotic administration. CONCLUSION: Pelvic actinomycosis is an extremely rare chronic infection. This entity is difficult to diagnose. Accurate diagnosis can reduce complications and unnecessary surgeries, and can preserve fertility.

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery.

INTRODUCTION AND IMPORTANCE: Three to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used. CASE PRESENTATION: We report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome. DISCUSSION: Perineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome. CONCLUSION: Lotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.