Metastatic colon carcinoma found within an enterocele sac: a case report

The incidental finding of cancer in a hernial sac is rare, but there are many case reports in the literature. There has never been a report of carcinoma found in an enterocele sac. We present the case of a 77-year-old female with symptomatic pelvic organ prolapse who presented for reconstructive pelvic surgery and was found to have metastatic adenocarcinoma contained within an enterocele sac. Incidental diagnosis of asymptomatic carcinoma found on typically discarded tissue from surgical procedures is rare. However, routine pathologic review of all tissue removed from a patient may save a life if carcinoma is found early.     

Enterocele manifesting as recurrent anterior rectal prolapse: A case report

Introduction and importanceAn enterocele is a true herniation of small bowel through the rectovaginal septum, most commonly occurring transvaginally. Although the prevalence of enterocele is not as low as previously thought, enteroceles manifesting transrectally or with rectal prolapse are exceedingly rare and without established surgical guidance.Case presentationA medically complex, oxygen-dependent patient presented with full fecal incontinence and transrectal enterocele associated with recurrent anterior rectal prolapse. This was diagnosed via defecography and repaired under regional anesthesia through an open transabdominal approach of posterior cul-de-sac obliteration, uterosacral ligament vaginal vault suspension and simplified ventral suture rectopexy. Surgical planning was determined through a multidisciplinary care-conference, with preference for an approach with minimal respiratory compromise and repair durability. Short-term, this patient has complete resolution of bulge symptoms, and improved fecal continence.Clinical discussionIn addition to history and examination, dynamic imaging of the pelvic floor, specifically defecography, is particularly useful in identifying enteroceles that present as a component of pelvic organ or anorectal prolapse. As there are no established standard surgical treatment approaches for these rare conditions, surgeons must consider several points prior to proceeding: the repair of the defect, the symptoms the repair targets, and repair durability.ConclusionsComplete assessment and specialist consultation should be pursued prior to surgical repair for anorectal pathology. For this patient, an open transabdominal native tissue repair under regional anesthesia was successful, emphasizing that approaches to surgical correction of such rare presentations must be individualized.     

Anterior enterocele: a report of three cases

Anterior enterocele is an uncommon finding in patients with pelvic organ prolapse. We reviewed 490 consecutive operations for pelvic organ prolapse . Three anterior enteroceles were identified in a series of 193 enterocele repairs (1.6%). The presentation and treatment of each of these patients is reviewed.This revised version was published online in June 2004 with corrections to the title.     

Incontinence and voiding difficulties associated with prolapse

Purpose

Prolapse is the protrusion of a pelvic organ beyond its normal anatomical confines. It represents the failure of fibromuscular supports.

Materials and Methods

A MEDLINE search was done using the keywords cystocele, uterine prolapse, vault prolapse, enterocele or rectocele in combination with urinary incontinence. We reviewed 97 articles. From this material the definition, classification, incidence, symptoms and evaluation are described.

Results

Prolapse and urinary incontinence often occur concomitantly and cystocele, rectocele, enterocele, uterine descent or vaginal vault prolapse may also be present. The pathophysiology of prolapse encompasses direct and indirect injury, metabolic abnormalities and chronic high intra-abdominal pressure. Anterior vaginal wall prolapse may present as stress incontinence. A large cystocele may cause urethral kinking and overflow incontinence. Uterine descent can cause lower back and sacral pain. Enterocele may cause only vague symptoms of vaginal discomfort. A rectocele can lead to incomplete evacuation of stool. A thorough history and physical examination are the most important means of assessment. A voiding diary helps determine functional bladder capacity. Uroflow examination determines the average and maximum flow rates, and the shape of the curve can help identify Valsalva augmented voiding. Multichannel urodynamics or videourodynamics with prolapse reduced can be important. The advantages of dynamic magnetic resonance imaging include excellent depiction of the soft tissues and pelvic organs, and their fluid content during various degrees of pelvic strain. To our knowledge whether it is cost-effective in this manner has not been determined.

Conclusions

Correction of prolapse must aim to restore vaginal function and any concomitant urinary incontinence.     

Unusual site of graft erosion after abdominal sacrocervicopexy

Large fasciomuscular damage of the feminine pelvic floor resulting in pelvic organ prolapse constitutes a challenge for surgical reconstruction.Between 2005 and 2010, ten women aged 47–75 years were treated by abdominoperineal implantation of polypropylene mesh for modified sacral perineocolporectopexy and subsequently followed up. They were suffering from enterocele (9), genital prolapse (8), descending perineum (5), rectal prolapse (4), and rectocele (3). Five women were incontinent (mean Wexner 9) and six had incomplete rectal evacuation. Defecography revealed enterocele III? (5) and II? (4). Magnetic resonance (MR) diagnosed descending perineum in five patients (mean 3.8 cm).Permanent reconstruction of the pelvic floor and remission of organ prolapse was achieved at 12-months of follow-up in all except one patient. There were two small vaginal mesh erosions and one hematoma within the pelvic floor. Improvement at rectal emptying and anal incontinence (mean Wexner 4) were found.Modified sacral perineocolporectopexy is effective in the treatment of complex pelvic floor anatomical defects and organ prolapse. Improvements in rectal emptying, pelvic feeling of heaviness, and dyspareunia were achieved. The procedure was safe and characterized by good implant tolerance and a low rate of complications.     

Fast magnetic resonance imaging of pelvic organ prolapse

Pelvic organ prolapse is abnormal displacement of the pelvic organs from their normal anatomical position. Patients may present with a variety of symptoms, including pain, incontinence, constipation, urinary retention, and defecatory dysfunction. Any combination of cystocele, rectocele, enterocele, sigmoidocele, peritoneocele, and prolapse of the vagina and uterus may occur. Therefore, accurate preoperative evaluation of each organ is important for proper surgical planning. Compared with physical examination and other imaging modalities, advantages of magnetic resonance imaging (MRI) include a global multiplanar view of the pelvis, and the lack of ionizing radiation and invasive procedures. Subsecond MRI techniques have not only shortened the imaging time to minimize motion artifacts but provide the capability for dynamic MRI. In this pictorial essay, we describe fast MRI techniques, MRI findings, and the associated clinical findings in patients with pelvic organ prolapse. We also refer to limitations of MRI.     

Pelvic organ prolapse after uterine artery embolization for uterine myoma

Uterine artery embolization (UAE) is gaining popularity as a treatment modality in patients with symptomatic uterine fibroids who do not desire fertility. Complications of this procedure can be serious and disabling. A 50-year-old woman presented with stage II uterovaginal prolapse after UAE for symptomatic uterine fibroids. Pelvic organ prolapse developed 16 months after the initial procedure. Surgical correction was performed. This is the first case report of pelvic organ prolapse after UAE. Normal prior gynecological examinations, and absence of pelvic pressure symptoms, indicate that pelvic organ prolapse had occurred subsequent to UAE.     

Enterocele repair by abdominal obliteration of the pelvic inlet: long-term outcome on obstructed defaecation and symptoms of pelvic discomfort

OBJECTIVE: Enterocele is defined as a herniation of the peritoneal sac between the vagina and the rectum. This may contain either sigmoid colon or small bowel. It has been reported that enterocele is associated with obstructed defaecation and symptoms of pelvic discomfort. The aim of the present study was to evaluate the long-term effect of enterocele repair. METHOD: In the time period between 1994 and 2003, 54 women (median age 54 years; range: 31-80) with a symptomatic enterocele underwent obliteration of the pelvic inlet with a U-shaped Mersilene mesh. All patients underwent evacuation proctography (EP), which was repeated 6 months after the repair. In addition, they were contacted over the telephone to assess the long-term effect of enterocele repair. Forty-nine patients were willing to answer questions over the telephone. Five patients were lost to follow-up (response rate: 91%). RESULTS: Six months after the procedure, EP revealed a recurrent or persistent enterocele in five (9%) patients, which was symptomatic in two, both of whom underwent a second repair. Among the 49 patients without an enterocele after 6 months, 10 (23%) women encountered recurrent symptoms of pelvic discomfort at a median follow-up of 85 months (range: 3-137). Despite adequate correction of the enterocele, obstructed defaecation persisted in 21 (75%) patients of 28, who presented with this problem before the procedure. De novo dyspareunia occurred in 5% of the women after the procedure. CONCLUSION: Obliteration of the pelvic inlet with a U-shaped Mersilene mesh provides an effective tool for anatomical correction of enteroceles. However, in the long term one of four patients encounters recurrent symptoms of pelvic discomfort. It seems unlikely that enterocele contributes to obstructed defaecation, as evacuation difficulties persist in around three quarters of the patients.     

Surgery for pelvic floor disorders

By careful observation of the physical findings in the patient complaining of one of the disorders of genital prolapse, it should be possible to discern the origin of the symptoms and therefore to devise an appropriate treatment that would remedy by reconstruction all of the signs of anatomic weakness. The goals of reconstructive surgery are three: to relieve the symptoms, to restore the anatomy to normal, and to restore the function to normal. When any element of weakness in the pelvic floor is found to be sufficient to produce symptoms that warrant repair, it is the responsibility of the surgeon to identify all the sites of weakness, so that all may be repaired at the same time, sparing the patient the expense, pain, and inconvenience of future readmission for further surgery. These weaknesses all relate to deficiencies of the six major organ systems that are involved in the support of the female pelvis, which may be damaged singly or in any combination. There are various types of cystocele, each of which must be carefully excised if an appropriate surgical treatment is to be given. This may involve correction of cystocele, enterocele, rectocele, prolapse of the uterus, and posthysterectomy prolapse of the vaginal vault. With enterocele, it is possible to correlate the four common types of enterocele with their location, which in turn correlates directly with their treatment. The prevention of complications is emphasized along with the treatment of certain mechanical complications easily recognized at the time of surgery.     

Actinomyces infection appearing five years after trocar-guided transvaginal mesh prolapse repair

Bacterial colonization and chronic infection following mesh-augmented pelvic floor reconstructive surgery may be one reason for abnormal healing and the occurrence of complications such as a mesh erosion, pain, and shrinkage. This case presents a patient with Actinomyces infection that appeared 5 years after trocar-guided transvaginal mesh repair of pelvic organ prolapse (POP). In patients with recurrent symptomatic mesh exposure, if partial removal or conservative treatment is unsuccessful, the possibility of Actinomyces infection should be considered.     

Apical vault repair, the cornerstone or pelvic vault reconstruction

Pelvic organ prolapse remains a difficult problem for pelvic reconstructive surgery. Before new surgical procedures can be developed a good understanding of pelvic anatomy is necessary. It is widely held that the etiology of pelvic organ prolapse is secondary to stretch neuropathy following childbirth and chronic cough or constipation. Several transvaginal and transabdominal procedures have been developed over the years. With the increasing use of laparoscopy, a new variation on existing culdeplasty techniques has been developed. Following anatomical principles, the apical vault repair reestablishes the pericervical ring at the vaginal apex. The incorporation of pubocervical fascia, uterosacral-cardinal ligament and the rectovaginal fascia provides a strong anchor for the vaginal apex. In addition, the repair should help prevent future transverse cystocele, rectocele, enterocele and apical vault prolapse. Early outcome studies suggest that the apical vault repair should be used routinely with laparoscopic urethropexy, laparoscopic hysterectomy and the repair of pelvic organ prolapse. Good apical vault support is considered the cornerstone of pelvic reconstruction.     

Place du traitement chirurgical par « voie haute »

Indications for surgical repair of rectocele are symptomatic large rectocele, patient with obstructive defecation syndrome (i.e. incomplete evacuation and digital support during defecation), patient with a rectocele of a depth of > 3 cm, or barium paste remaining trapped in the cavity after evacuation. Rectocele often coexists with other pelvic organ prolapses, such as cystocele, vaginal vault prolapse and enterocele. For these reasons, surgical rectocele treatment is designed to reduce specific symptoms and requires a multidisciplinary approach. What constitutes the optimal surgical approach has been debated for some considerable time. Various surgical techniques with a transanal, transperineal, transvaginal or abdominal approach have been used for rectocele. No randomized trial has clearly established the best approach. A laparoscopic sacral colpopexy approach is effective for genito-urinary prolapse associated with rectocele. Furthermore, laparoscopic ventral recto(colpo)pexy is a innovative technique that avoids any posterolateral rectal mobilization, thus minimizing the risk of autonomic neural damage. The unique anterior placement of the mesh with reinforcement of the rectovaginal septum restores normal rectal evacuation. The abdominal approach seems the most suitable for rectocele in sexually active women because it is not associated with dyspareunia. Two surgical techniques may be proposed, either laparoscopic double sacral colpopexy using prosthetic materials, or laparoscopic ventral recto(colpo)pexy.     

Urogenitals prolapse: revision of concepts

The prolapse is the exteriorization of the pelvic organs through the vagina, this condition may affect the quality of life. The prolapse was diagnosed in 50% of multiparous women. It is estimated that a woman throughout her life, has 11% risk of needing surgery for correction of pelvic organ prolapse or urinary incontinence. The prolapse may occur at the anterior vaginal wall (cystocele) at the vaginal, uterus (histerocele) or at the posterior wall (or rectocele enterocele). For the unfit patient obliteratives procedures may be indicated and recontructives for pacients wih good performance status. It is important for reconstructive surgery a correct diagnosis, for the specific defect repair. When indicated, meshes can be used to add strength to the poor quality tissues.     

Appendectomy for appendicitis in patients with a prior ventriculoperitoneal shunt

BACKGROUND: Approximately 18,000 cerebrospinal fluid shunts, the majority of which are ventriculoperitoneal, are placed each year in the United States. These patients may develop appendicitis and require surgery. Whether the risk of postoperative complications is increased in these patients is unknown. We sought to determine the clinical course of patients with ventriculoperitoneal (VP) shunts who undergo appendectomy for appendicitis. METHODS: A nationwide search of Department of Veterans Affairs databases was conducted to identify patients with a VP shunt who subsequently developed appendicitis and underwent appendectomy. Patient medical records were analyzed to determine if the presence of a VP shunt affected the surgical approach or the postoperative course of patients who underwent appendectomy. RESULTS: Ten patients had ICD-9-CM codes for both appendectomy and a VP shunt. Five met the inclusion criteria for the study and had sufficient data for analysis. Medical records indicated that all of the patients had perforated or gangrenous appendicitis with peritonitis. One patient's VP shunt was converted to a ventriculoatrial shunt. Another patient's shunt was removed when culture of his peritoneal fluid grew Gram-positive cocci. There were no instances of postoperative infection, shunt malfunction, or other complication. CONCLUSION: This is the only English language study, to our knowledge, of the clinical course of adults with VP shunts in place at the time of appendectomy for appendicitis. Such patients generally have no complications related to shunt malfunction or infection. In a minority of patients, shunt revision may be required.     

Treatment of enterocele by abdominal colporectosacropexy – efficacy on pelvic pressure

Objective Enterocele induces pelvic pressure, obstructed defaecation, lower abdominal pain and/or false urge to defaecate in patients. The aim of this study was to evaluate the efficacy of abdominal colporectosacropexy in these symptoms, especially on pelvic pressure. Methods Sixty‐two consecutive women with enterocele were included. All patients were symptomatic because they had: pelvic pressure (n = 62), obstructed defaecation (n = 40), lower abdominal pain (n = 8) or faecal incontinence (n = 16). Defaecography confirmed enterocele in all patients. The surgical procedure was performed by the same surgeon and was an abdominal colporectosacropexy with a nonabsorbable Prolene® mesh. After surgery, clinical evaluation (62/62 patients) and a telephone questionnaire (56/62 patients) were performed, respectively, 3 months and 27 ± 13 months after surgery. Results Defaecography showed rectal abnormalities associated with enterocele in 59/62 patients (rectocele, rectal prolapse). No recurrence of enterocele was observed 3 months after surgery, but 1 patient demonstrated recurrence 10 months after surgery. Pelvic pressure was less frequent after abdominal colporectosacropexy, than before surgery (P < 0.01): pelvic pressure totally disappeared in 41/56 patients, and partially in 10/56 patients. The number of patients with obstructed defaecation, lower abdominal pain, or faecal incontinence was not different before and 27 months after surgery. The number of patients with urinary incontinence was also not different before and after surgery (30 and 27 patients). Conclusions This study of a large number of patients with enterocele shows that abdominal colporectosacropexy improves pelvic pressure in most patients and does not modify urinary status.     

Correlation between posterior vaginal wall defects assessed by clinical examination and by defecography

To estimate the accuracy of clinical examination and the indications for defecography in patients with primary posterior wall prolapse. Fifty-nine patients with primary pelvic organ prolapse were evaluated with a questionnaire, clinical examination and defecography. Defecography was used as reference standard. There was no relation between bowel complaints and posterior wall prolapse evaluated by clinical examination (p = 0.33), nor between bowel complaints and rectocele (p = 0.19) or enterocele (p = 0.99) assessed by defecography. The diagnostic accuracy of clinical examination in diagnosing rectocele was 0.42, sensitivity was 1.0 and specificity was 0.23. The diagnostic accuracy of clinical examination in diagnosing enterocele was 0.73, with a sensitivity of 0.07 and a specificity of 0.95. Clinical examination is not accurate to assess anatomic defects of the posterior vaginal wall. Defecography is recommended as a helpful diagnostic tool in the work-up of patients with posterior vaginal wall prolapse if surgical repair is considered.     

Small bowel incarceration associated with posthysterectomy enterocele

Enterocele represents a pelvic floor hernia with the sac most commonly protruding between the rectum and vagina. It may occur with or without prior hysterectomy and is very rarely complicated by small bowel obstruction. We report herein the case of a 70-year-old woman with a posthysterectomy enterocele presented with symptoms of small bowel obstruction and abdominal tenderness. The patient underwent exploratory laparotomy, which revealed small bowel incarceration. To our knowledge, this case represents the first published case of vaginal vault prolapse and enterocele associated with small bowel obstruction and incarceration. The pathogenesis, diagnosis, and treatment are discussed.     

Dynamic magnetic resonance imaging to quantify pelvic organ prolapse: reliability of assessment and correlation with clinical findings and pelvic floor symptoms

Introduction and hypothesis

The aim of this study was to assess the interobserver agreement of magnetic resonance imaging (MRI)-based staging of pelvic organ prolapse (POP) and to quantify associations between MRI-based POP staging, findings at pelvic examination, and pelvic floor symptoms.

Methods

This was a cross-sectional study of ten symptomatic POP patients, ten symptomatic patients without POP, and ten nulliparous asymptomatic women. Three different observers performed MRI-based POP staging using the pubococcygeal line (PCL), midpubic line (MPL), perineal line, and H line as references.

Results

The interobserver agreement of MRI-based staging of the anterior and middle compartment was good to excellent. In symptomatic women without prolapse, MRI-based and pelvic-examination-based POP staging were poorly correlated. In none of the women were MRI-based POP Quantification (POP-Q) staging and pelvic floor symptoms strongly associated.

Conclusion

The interobserver agreement of MRI-based POP staging is excellent, but the added clinical value of such staging is questionable due to poor association with clinical findings and pelvic floor symptoms.     

Shunt tube problems due to placement of valves on the chest wall--three case reports

Programmable valves are often used for ventriculoperitoneal (VP) shunts with the shunt valve positioned on the chest wall. Three cases of shunt problems occurred due to placement of the valve on the chest wall. A 43-year-old male was treated with a VP shunt, and suffered shunt malfunction due to dislocation of the ventricular tube. A 21-year-old male was treated with a VP shunt, and suffered shunt malfunction due to disconnection of the shunt tube. A 4-day-old female neonate was treated with a VP shunt, and suffered migration of the shunt valve. The shunt system has two anchor sites on the head and chest wall, with the neck between the two anchor sites. High tension is sometimes caused in the shunt tube between the two points due to movement of the neck or growth, and may induce such dislocation and disconnection of the shunt tube. We recommend a longer shunt tube in such cases.