A Diagnostic Conundrum - Small bowel obstruction from undiagnosed endometriosis following uterine perforation.

INTRODUCTION: Uterine perforation is a rare but recognized complication from dilation and curettage, a common therapeutic procedure for obstetric complications and emergencies. Limited cases exist on endometriosis occurring following rupture. Additionally, there are no reported cases of uterine rupture secondary to dilation and curettage leading to new onset endometriosis first presenting as a small bowel obstruction (SBO). PRESENTATION OF CASE: A 42-year-old female with recurrent small bowel obstruction was found to have a stricture caused by endometriosis via diagnostic laparoscopy and pathology. Patient had a dilation and curettage for retained products of conception 11 years prior, complicated by uterine perforation. This patient never had a diagnosis of endometriosis prior to her SBO. Patient made an uneventful recovery after small bowel resection with resolving of SBO symptoms. DISCUSSION: Our case highlights the possibility of endometriosis due to previous uterine rupture as a cause for SBO in an otherwise healthy, female patient of reproductive age. There is a continued need for appropriate documentation of surgical complications on patient charts as well as considering postoperative complications when other etiologies of SBO are less likely. CONCLUSION: Endometriosis should be considered as a differential in reproductive aged women presenting with a small bowel obstruction, with an increased index of suspicion if the patient has had previous obstetric surgical procedures.

Role of epidural and patient-controlled analgesia in site-specific laparoscopic colorectal surgery.

BACKGROUND AND OBJECTIVES: Limited data are available comparing epidural and patient-controlled analgesia in site-specific colorectal surgery. The aim of this study was to evaluate 2 modes of analgesia in patients undergoing laparoscopic right colectomy (RC) and low anterior resection (LAR). METHODS: Prospectively collected data on 433 patients undergoing laparoscopic or laparoscopic-assisted colon surgery at a single institution were retrospectively reviewed from March 2004 to February 2009. Patients were divided into groups undergoing RC (n = 175) and LAR (n = 258). These groups were evaluated by use of analgesia: epidural analgesia, "patient-controlled analgesia" alone, and a combination of both. Demographic and perioperative outcomes were compared. RESULTS: Epidural analgesia was associated with a faster return of bowel function, by 1 day (P < .001), in patients who underwent LAR but not in the RC group. Delayed return of bowel function was associated with increased operative time in the LAR group (P = .05), patients with diabetes who underwent RC (P = .037), and patients after RC with combined analgesia (P = .011). Mean visual analogue scale pain scores were significantly lower with epidural analgesia compared with patient-controlled analgesia in both LAR and RC groups (P < .001). CONCLUSION: Epidural analgesia was associated with a faster return of bowel function in the laparoscopic LAR group but not the RC group. Epidural analgesia was superior to patient-controlled analgesia in controlling postoperative pain but was inadequate in 28% of patients and needed the addition of patient-controlled analgesia.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for the treatment of peritoneal sarcomatosis.

BACKGROUND: The prognosis of peritoneal sarcomatosis is generally poor and conventional treatments for this disease process are mostly ineffective. The use of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as an aggressive locoregional treatment option remains controversial. METHODS: We reviewed 13 patients with peritoneal sarcomatosis who underwent CRS and closed-abdomen HIPEC with cisplatin and doxorubicin between March 2007 and March 2010. None of the patients was diagnosed with GIST or uterine leiomyosarcoma. Both disease-free survival (DFS) and overall survival (OS) were evaluated. Completeness of cytoreduction (CC) and peritoneal cancer index (PCI) were assessed. RESULTS: There was no operative mortality. Median follow-up was 12 (range, 4­43) months. Peritoneal disease progression occurred in six patients, distant metastases alone in none, and both in two patients. Median DFS and OS were 11 and 12 months, respectively. Completeness of cytoreduction significantly affected survival. Mean DFS and OS in those patients where a CC-0 was achieved was 27.25 ± 5.71 (median, 20) months and 35.25 ± 4.75 months (median, not reached). In contrast, patients with gross residual disease (CC ≥ 1) had a DFS of 4.25 ± 1.43 months (median, 4 months; P = 0.03) and an OS of 5.25 ± 2.36 months (median, 4 months; P = 0.02). In addition, PCI influenced survival when evaluated by univariate analysis. Using multivariate analysis, completeness of cytoreduction was the only covariate influencing overall survival (P = 0.012). CONCLUSIONS: A complete cytoreduction and low PCI score appear to be important factors in considering CRS and HIPEC for patients with peritoneal sarcomatosis.

Ultrasound-guided excision of nonpalpable malignant soft tissue tumors of the abdomen.

The use of intraoperative ultrasound to guide the excision of sonographically visible but nonpalpable lesions is a newer modality. Its use in intraoperative localization of recurrent malignant soft tissue tumors has not been reported. This report describes a technique of intraoperative localization by ultrasound to guide the excision of recurrent nonpalpable malignant soft tissue tumors of the abdominal wall in two patients. Tumors of both patients were successfully localized intraoperatively by ultrasonography and excised with adequate margins. This technique leads to reduced patient discomfort and anxiety, the avoidance of organizational requirements on the day of surgery, and allows for adequate margins of resection.