Prise en charge chirurgicale des abcès tubo-ovariens compliquant une endométriose profonde

Successful minimally invasive surgery for postpartum retroperitoneal hematoma complicated by an infection: Two case reports

Introduction

and importance Postpartum retroperitoneal hematoma is a birth canal injury that is difficult to diagnose because of its invisibility. Secondary infections of these hematomas are rare, and their diagnostic and management strategies have not been fully elucidated. We present two cases of postpartum retroperitoneal hematomas with infection, which were successfully treated with minimally invasive surgery.

Case presentation

Case 1 was of a 2X-year-old woman who presented with complaints of fever; a provisional diagnosis of chorioamnionitis and Streptococcus pyogenes-induced sepsis was made. Case 2 was of a 3X-year-old woman who underwent uterine artery embolization and manual removal of the placenta for suspected placenta accreta. Both cases were diagnosed with adnexal hematomas, and antibiotic therapy failed in both patients. Therefore, we performed exploratory laparoscopy and made a diagnosis of retroperitoneal hematomas with infection; laparoscopic drainage resulted in rapid resolution of the clinical symptoms and abnormal blood test results.

Clinical discussion

Once an abscess develops, antibiotic treatment has a limited effect, and surgical drainage should be performed. Management of retroperitoneal hematomas is difficult, especially when complicated by an infection.

Conclusion

Minimally invasive procedures involving laparoscopy could be beneficial for the management of postpartum retroperitoneal hematomas complicated by an infection.

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Postpartum retroperitoneal hematoma is difficult to diagnose.

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Secondary infections of these hematomas are rare.

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The diagnosis and management strategies have not been fully elucidated.

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Management of retroperitoneal hematomas complicated by infection is challenging.

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Laparoscopy helps manage postpartum retroperitoneal hematomas with infection.

Inflammation calls for more: Severe pelvic inflammatory disease with or without endometriosis. Outcomes on 311 laparoscopically treated women

OBJECTIVE

To study possible associations between endometriosis and pelvic inflammatory disease (PID).

DESIGN

Retrospective cohort analysis over 14 consecutive years, based on medical records and insurance coding in a tertiary care endometriosis reference center.

SETTING

Tertiary care reference center for endometriosis.

PATIENTS

Retrospective analysis on all women submitted to laparoscopy in our Unit MAIN OUTCOME MEASURES: Intra-operative data about complications and fertility-impairing procedures, intra-, peri- and post-operative complications.

INTERVENTIONS

Retrospective disease codes-triggered chart analysis.

RESULTS

The study population was divided into two groups: Group 1 included women with PID and no endometriosis (n = 115); Group 2 included women with PID and endometriosis (n = 96). Endometriosis had a prevalence of 63 % in patients submitted to surgery for PID, significantly higher than the one reported in general population and than the one reported in a Tertiary Care Endometriosis Unit. A significantly higher number of salpingectiomes was needed in group 2 patients (208 versus 80, p < 0.0001).

CONCLUSIONS

This study seems to confirm an higher prevalence of pelvic inflammatory disease in endometriosis patients. Intra-operative findings of PID with associated endometriosis show more aggressive patterns.

Middlemore Hospital experience with tubo-ovarian abscesses: an observational retrospective study

AIM

The aim of this paper was to study the characteristics of patients presenting to Middlemore Hospital with tubo-ovarian abscess (TOA) and to compare the outcomes of conservative medical management versus medical management with surgical drainage and medical management with radiological drainage.

METHODS

All patients admitted with a radiologically or surgically proven TOA between January 01, 2008 and December 31, 2010, were included and followed up until June 30, 2011. The total number of patient/index admission was 174.

RESULTS

The mean age of patients was 37.8 years. One hundred thirty patients had medical treatment only with hospitalization and antibiotics, and 44 patients were managed with antibiotics and surgical drainage. Complete resolution of TOA was 77.3% (99/128) for patients managed medically and 93.2% (41/44) for patients managed surgically. When the two groups were compared, patients who were managed surgically were more likely to have complete resolution of TOA within 6 months of index admission with an odds ratio (OR) of 4 and a P-value of 0.029. There was no statistically significant difference in the secondary outcomes namely of readmission with TOA (OR: 0.47) and the need for repeat surgical or radiological drainage (OR: 1.48). Nonetheless, the relative duration of hospitalization was longer for the surgical group with a P-value of <0.0001. The C-reactive protein and the size of TOA were the significant factors involved in the resolution of TOA.

CONCLUSION

The results of this study confirmed our initial hypothesis that we should consider surgical drainage more often, probably earlier, especially for the younger patients still desiring fertility preservation and for larger abscesses. Laparoscopic surgical drainage is safe and could be used as the procedure of choice. Conservative medical management is still acceptable with good cure rates of 77%. C-reactive protein and the size of the abscess were the important factors to consider when managing patients with TOA.

Risks of tubo-ovarian abscess in cases of endometrioma and assisted reproductive technologies are both under- and overreported

OBJECTIVE

To study possible associations among endometriosis, pelvic infectious disease, and ART.

DESIGN

Retrospective cohort analysis over 4 consecutive years, based on medical records and insurance coding in a tertiary endometriosis reference center.

SETTING

Tertiary university-based reference center for endometriosis.

PATIENT(S)

We retrieved all charts carrying the diagnoses infectious process and endometriosis in 2009-2012. Each chart was individually analyzed for categorization of the infectious episode and determining whether ART had been performed.

MAIN OUTCOME MEASURE(S)

Hospitalization for acute infection in women with known endometriosis and possible past ART.

INTERVENTION

Retrospective insurance codes-triggered chart analysis.

RESULT(S)

Ten patients were admitted for an acute infection with fever, acute abdomen syndrome, elevated white blood cell count, and adnexal mass. Three women had oocyte retrieval, and an endometrioma was present 16, 57, and 102 days earlier. In one patient, the complication occurred 37 days after a cesarean section without prior ART. In the remaining six cases tubo-ovarian abscesses (TOAs) occurred spontaneously in endometriosis women who never had ART. Medical treatment succeeded in only two patients, and the remaining eight needed laparoscopic drainage. In 6 out of those 8 cases, laparoscopic drainage was a second-stage measure justified by failure to respond to antibiotic therapy.

CONCLUSION(S)

Our data indicate that some putative complications of ART and endometrioma may actually not be linked to ART, but rather constitute sporadic occurrences in endometriosis. Furthermore, TOAs occurring in women with endometriosis are best treated by early surgical drainage together with intravenous antibiotics.

[Treatment of the tubo-ovarian abscesses]

The antibiotic treatment is indispensable for the treatment of the tubo-ovarian abscesses (TOA). It has to have a wide spectre and would be secondarily adapted in case of a sexually transmitted infection. The surgery remains indicated in first intention in case of vital threat (generalized peritonitis, toxic shock). In the not complicated TOA, the evacuation of abscesses (by draining under imaging or laparoscopy) with the antibiotic treatment gives better rates of cure than the antibiotic treatment alone. For the surgery, several entrys are possible. The laparoscopy allows a shorter hospitalization with fewer complications and a faster resolution of the fever than the laparotomy. The conservative surgery, realized by laparoscopy, has hight rates of successes with few complications. The radical surgery, by coelioscopy or by laparotomy, has high rates of complications. Transvaginal ultrasound guided aspiration is an alternative in the drainage by laparscopy with identical succes. It has been well evaluated. It has low morbidity and can be proposed in first intention in not complicated TOA.