Pancreatolithiasis: Does Management Depend on Clinical Manifestations?

BACKGROUND Pancreatic calculi (PC) or pancreatolithiasis refers to the presence of stones in the main pancreatic duct (MPD), side branches, or parenchyma of the pancreas. It is highly associated with chronic pancreatitis (CP), and is present in 50-90% of those patients. The stone formation can be attributed to a diversity of factors, all of them leading to obstruction in the duct, hypertension of its distal part, increased intraductal and parenchymal pressure, and inflammation, causing the standard symptom, epigastric pain. Immediate restoration of pancreatic secretion flow is of utmost importance and can be achieved with both endoscopic and surgical techniques. Endoscopic techniques include endoscopic retrograde cholangiopancreatography (ERCP) combined, if possible, with extracorporeal shock wave lithotripsy (ESWL), while surgical techniques consist of drainage and resection procedures. The choice of treatment for PC depends on the location, size, and number of stones, and the existence of other complications. CASE REPORT We present 2 cases that were diagnosed with PC, in which clinical symptoms, laboratory results, and imaging examinations were different, suggesting the variety of manifestations pancreatolithiasis can cause. Each patient was treated differently, according to their clinical situation and the presence or absence of complications. Both patients were discharged and fully recovered. CONCLUSIONS The management of pancreatolithiasis can be demanding in some cases, mostly when there are complications. The purpose of this case report is to indicate the importance of personalized treatment for each patient, as different approaches to the same medical condition should be easily identified and successfully treated.

A Rare Case of a Direct Incarcerated Inguinal Hernia Containing an Epiploic Appendage and a Literature Review

Inguinal hernias are a widespread condition, responsible for a large number of acute abdomen cases. Typically, indirect, rather than direct, hernias lead to complications, as a consequence of their narrower hernial defect. We report a 71-year-old male patient with a rather rare incidence of a direct incarcerated hernia who presented with acute pain in the left inguinal area at a university general hospital in Thessaloniki, Greece, in 2017. Upon clinical examination, an irreducible inguinal mass was palpated. Therefore, the existence of a complicated hernia was suspected. The patient underwent an emergency repair, during which it was established that the hernia was direct and incarcerated and that its sac contained an ischaemic epiploic appendage. The hernia was successfully repaired with mesh, the patient recovered uneventfully and was discharged five days later. Despite the rarity of complicated direct inguinal hernias, they should always be included in the differential diagnosis of irreducible groin masses as they can increase severe complications.

Gastrointestinal Stromal Tumors: Our Ten-Year Experience of a Single-Center Tertiary Hospital

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal neoplasms of the gastrointestinal tract. They have variable clinical presentation, prognosis, and molecular characteristics. Here, we present the results of our retrospective study including patients operated on for GIST during the last decade.

METHODS

All the patients who underwent GIST resection during the decade 2008-2018 were included in the study. The diagnosis was based on the pathology report. All the data were collected and analyzed statistically using the Statistical Package for Social Science v25.0. Finally, after having applied the proper search terms, a comprehensive review of articles published in the Medline database was held.

RESULTS

Thirty-two patients (sixteen women) were included in the study with a mean age of 69.6 years old (SD = 13.9). Twenty-one patients had a GIST in the stomach, eight in the small intestine, and three had an extra GIST. Of the 29 patients contacted, 21 were alive with a mean survival time of 74.3 months (SD = 49.6 months, min: 3.0 months, max: 161.0 months), whereas eight patients passed away. Finally, 13 patients were treated with tyrosine kinase inhibitors (TKIs) of whom only one died, while 9 patients passed away from those treated with surgery alone (p = 0.031).

CONCLUSIONS

Our results were in concordance with the existing data in the literature. GISTs require patient-based therapeutical management depending on the histology of the tumors. Gastric tumors present a better prognosis than those localized in the intestine, while the use of TKIs has led to an improvement in patient survival rate.

Bowel Perforation in Vascular Ehlers-Danlos Syndrome: Case Report and Comprehensive Review

INTRODUCTION

Ehlers-Danlos syndromes (EDS) comprise a rare variety of genetic disorders, affecting all types of collagen. Herein, we describe a case of the vascular type of EDS, with coexisting segmental absence of intestinal musculature, while simultaneously performing a narrative review of the existing literature.

CASE PRESENTATION

A 23-year-old male patient with a history of multiple abdominal operations due to recurrent bowel perforations and the presence of a high-output enterocutaneous fistula was admitted to our surgical department for further evaluation and treatment. After detailed diagnostic testing, the diagnosis of vascular-type EDS (vEDS) was made and a conservative therapeutic approach was adopted. In addition, a comprehensive review of the international literature was carried out by applying the appropriate search terms.

RESULTS

The diagnosis of vEDS was molecularly confirmed by means of genetic testing. The patient was treated conservatively, with parenteral nutrition and supportive methods. Thirty-four cases of bowel perforation in vEDS have been reported so far. Interestingly, this case is the second one ever to report co-existence of vEDS with Segmental Absence of Intestinal Musculature.

CONCLUSIONS

Establishing the diagnosis of vEDS promptly is of vital significance in order to ensure that patients receive appropriate treatment. Due to initial non-specific clinical presentation, EDS should always be included in the differential diagnoses of young patients with unexplained perforations of the gastrointestinal tract.

How far is the endoscopist to blame for a percutaneous endoscopic gastrostomy complication?

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a well-established, minimally invasive, and easy to perform procedure for nutrition delivery, applied to individuals unable to swallow for various reasons. PEG has a high technical success rate of insertion between 95% and 100% in experienced hands, but varying complication rates ranging from 0.4% to 22.5% of cases.

AIM

To discuss the existing evidence of major procedural complications in PEG, mainly focusing on those that could probably have been avoided, had the endoscopist been more experienced, or less self-confident in relation to the basic safety rules for PEG performance.

METHODS

After a thorough research of the international literature of a period of more than 30 years of published “case reports” concerning such complications, we critically analyzed only those complications which were considered - after assessment by two experts in PEG performance working separately - to be directly related to a form of malpractice by the endoscopist.

RESULTS

Malpractice by the endoscopist were considered cases of: Gastrostomy tubes passed through the colon or though the left lateral liver lobe, bleeding after puncture injury of large vessels of the stomach or the peritoneum, peritonitis after viscera damage, and injuries of the esophagus, spleen, and pancreas.

CONCLUSION

For a safe PEG insertion, the overfilling of the stomach and small bowel with air should be avoided, the clinician should check thoroughly for the proper trans-illumination of the light source of the endoscope through the abdominal wall and ensure endoscopically visible imprint of finger palpation on the skin at the center of the site of maximum illumination, and finally, the physician should be more alert with obese patients and those with previous abdominal surgery.

Uroperitoneum as a Complication of Laparoscopic Cholecystectomy: A Case Report

BACKGROUND

Bladder rupture is more frequently encountered in blunt pelvic trauma, but can also be spontaneous or iatrogenic. Laparoscopic repair has been widely used during the last few years as a treatment for intraperitoneal bladder perforation. The bladder is the genitourinary organ most often affected by iatrogenic injury. The purpose of this article is to report what is, to our knowledge, the first documented case of bladder rupture as a complication of laparoscopic cholecystectomy.

CASE DESCRIPTION

A 51-year-old female presented to the emergency department complaining about generalized abdominal pain on the sixth postoperative day after laparoscopic cholecystectomy. Laboratory results highlighted a significant impact on renal function while the abdominal CT scan demonstrated free intraperitoneal fluid collection and surgical clips in the anatomic region of the liver and in an ectopic position near the ileocecal valve. An explorative laparoscopy revealed a 2 cm defect in the superior bladder wall, which was repaired in one layer in a continuous-locking fashion. The patient was discharged home on the fifth postoperative day having an uneventful recovery.

CONCLUSION

Bladder rupture frequently presents with non-specific clinical signs; as a result, it is easily misdiagnosed, especially when it occurs with a non-typical mechanism of injury. Pseudorenal failure is a relatively obscure entity that may help the clinician suspect a bladder perforation. Laparoscopic repair with a single-layer continuous suture technique is a safe and feasible treatment in hemodynamically stable patients. Prospective research is required to specify the optimal timing of catheter removal after bladder repair.

A Rare Case of a Direct Incarcerated Inguinal Hernia Containing an Epiploic Appendage and a Literature Review

Inguinal hernias are a widespread condition, responsible for a large number of acute abdomen cases. Typically, indirect, rather than direct, hernias are the ones leading to complications, as a consequence of their narrower hernial defect. Our case concerns a rather rare incidence of a direct incarcerated hernia in a 71-year-old man who presented with acute pain in the left inguinal area. Upon clinical examination, an irreducible inguinal mass was palpated. Therefore, the existence of a complicated hernia was suspected. The patient underwent an emergency repair, during which it was established that the hernia was direct and incarcerated and that its sac contained an ischemic epiploic appendage. The hernia was successfully repaired with mesh, the patient recovered uneventfully and was discharged five days later. Despite the rarity of complicated direct inguinal hernias, they should always be included in the differential diagnosis of irreducible groin masses, because they can increase severe complications. Keywords: Direct inguinal hernia; Appendix epiploica.

Right Paraduodenal Hernia as a Cause of Acute Abdominal Pain in the Emergency Department: A Case Report and Review of the Literature

Paraduodenal hernias (PDHs) represent an unusual cause of acute abdominal pain in the Emergency Department (ED) and are associated with high morbidity attributable to a challenging clinical and radiological diagnosis, as signs and symptoms mimic other frequent causes of acute abdominal pain. We report a right paraduodenal hernia in a 37-year-old female patient who presented to the ED complaining of abdominal pain located in the right lower abdomen and hypogastrium, accompanied by nausea. During diagnostic work up, the abdominal computed tomography scan revealed the presence of small bowel malrotation with concomitant right paraduodenal hernia. These findings were confirmed intraoperatively. We performed a brief literature review about the clinical manifestations and treatment options of right paraduodenal hernias, which retrieved only 30 articles related to this condition. Prompt diagnosis, radiological or intraoperative, of paraduodenal hernias is crucial because nearly 50% will progress to small bowel obstruction. Therefore, it is essential for every clinician to account for them in the differential diagnosis of acute abdominal pain in the ED.

Abdominal cocoon syndrome: Rare cause of intestinal obstruction-Case report and systematic review of literature

BACKGROUND

Abdominal cocoon or sclerosing encapsulating peritonitis is an uncommon condition in which the small bowel is completely or partially encased by a thick fibrotic membrane. Our study presents a case of sclerosing encapsulating peritonitis and conducts a literature review.

METHODS

A bibliographic research was conducted. Our research comprised 97 articles. Gender, age, symptoms, diagnostic procedures, and treatment were all included in the database of patient characteristics.

CASE PRESENTATION

A 51-year-old man complaining of a 2-day history of minor diffuse abdominal pain, loss of appetite, and constipation was presented in emergency department. Physical examination was indicative of intestinal obstruction. Laboratory tests were normal. Diffuse intraperitoneal fluid and dilated small intestinal loops were discovered on computed tomography (CT). An exploratory laparotomy was recommended, in which the sac membrane was removed and adhesiolysis was performed. He was discharged on the tenth postoperative day.

RESULTS

There were 240 cases of abdominal cocoon syndrome in total. In terms of gender, 151 of 240 (62.9%) were male and 89 of 240 (37%) were female. Ages between 20 and 40 are most affected. Symptoms include abdominal pain and obstruction signs. For the diagnosis of abdominal cocoon syndrome, CT may be the gold standard imaging method. The surgical operation was the treatment of choice in the vast majority of cases (96.7%). Only 69 of 239 patients (28.9%) were detected prior to surgery, and CT was applied in these cases.

CONCLUSION

Abdominal cocoon is a rare condition marked by recurrent episodes of intestinal obstruction. Surgical therapy is the most effective treatment option.

Rubber band ligation of hemorrhoids: is the procedure effective for the immunocompromised, hemophiliacs and pregnant women?

Background

Rubber band ligation (RBL) is an effective, well-established, non-surgical option for symptomatic grade II-III hemorrhoid treatment. However, few reports exist about the benefit and risks of RBL in high-risk patients. We herein evaluated the effectiveness and safety of RBL in hemophiliac, human immunodeficiency virus (HIV)-positive and pregnant patients vs. other patients.

Methods

We retrospectively evaluated the effectiveness of RBL, during the period 2001-2021, in 3 distinct patient categories deemed high-risk and thus not suitable for anesthesia and/or surgical management of their hemorrhoids: hemophiliacs, HIV-positive patients, and pregnant women. These were compared to matched controls, selected from our outpatient pool, who had no major comorbidities and who had opted for RBL as the primary method of treatment.

Results

There were 3 study groups (44 with hemophilia, 29 HIV-positive patients, and 45 pregnant women) and controls respectively matched for grade, sex and age (2 for each one in the study groups). Hemophilia patients needed up to 6 RBL sessions for relief of symptoms (3.22 sessions/patient) compared to controls, who needed up to 4 sessions (1.88 sessions/patient, P<0.001); in the other 2 groups there was no difference. There were 3 minor complications: one minor bleeding in a hemophilia patient, a thrombosis in an HIV-positive patient, and severe rectal pain in a control patient. Patients were followed-up for at least 1 year.

Conclusion

RBL is a safe and effective procedure in hemophiliacs, HIV-positive patients and pregnant women, with low complication rates for grade I-III hemorrhoids, similar to those in healthy matched controls.

The effect of intraoperative autofluorescence monitoring on unintentional parathyroid gland excision rates and postoperative PTH concentrations-a single-blind randomized-controlled trial

PURPOSE

Intraoperative imaging of parathyroid glands (PGs) has been developed in order to reduce the risk of unintentional parathyroidectomy during total thyroidectomy. This novel modality is based on their intrinsic characteristic of autofluorescence (AF) after near-infrared light exposure. The aim of this study was to assess the effect of this method on the risk of unintentional PG excision (total or partial) during total thyroidectomy.

METHODS

This was a single-blind, randomized-controlled trial including adult patients who underwent scheduled total thyroidectomy between December 2019 and March 2020. These patients were randomly allocated to two groups: one in which near-infrared autofluorescence imaging (NIRAF) was applied (NIR group) and one without NIRAF (NONIR group). Hormonal and biochemical assessment was performed pre- and 24-h postoperatively. AF findings and the number of PGs autotransplanted were recorded.

RESULTS

One-hundred and eighty patients were eligible. Unintentional (total or partial) PG excision rates during total thyroidectomy in the NONIR (n = 90) and NIR (n = 90) groups were 28.9% [95% confidence interval (CI) 19.8-39.4%] and 14.4% (95% CI 7.7-22.1%), respectively (p = 0.02). Furthermore, NIR reduced the risk of parathyroid tissue presence in the specimen sent for pathology (relative risk 0.51, 95% CI 0.28-0.92; p = 0.02). However, the number of PGs identified by NIR could not predict the risk of postoperative hypoparthyroidism.

CONCLUSIONS

NIRAF imaging during total thyroidectomy led to a significant reduction in PG excision rates. However, this modality did not result in the reduction of postoperative hypoparathyroidism or hypocalcemia risk.

Do Near-Infrared Intra-Operative Findings Obtained Using Indocyanine Green Correlate with Post-Thyroidectomy Parathyroid Function? the Icgpredict Study

OBJECTIVE

Postoperative hypoparathyroidism (hypoPT) still remains a significant complication after thyroidectomy. Intra-operative imaging modalities, such as near-infrared fluorescence using indocyanine green (ICG), may assist in identifying and preserving the parathyroid glands (PGs). The purpose of this study was to test the association between the intra-operative ICG staining scoring system and 24-hour postoperative parathyroid hormone (PTH) levels, as well as its capability for intra-operative PG identification.

METHODS

This was a prospective study, recruiting patients scheduled for total thyroidectomy by the same surgical team, from December 2018 to April 2019. Intra-operative angiography was performed after infusion of ICG solution (5 mg). Two minutes later, images were acquired using the near-infrared system.

RESULTS

Sixty patients fulfilled the eligibility criteria. The percentage of temporary postoperative hypoPT (defined as PTH <14 pg/mL) was 11.66%. No association between intra-operative ICG staining score (expressed as the number of PGs scoring <2 per patient) and 24-hour postoperative PTH (r = 0.011; P = .933) or serum calcium concentrations (r = 0.127; P = .335) was observed. There was also no correlation between the location of PGs scoring ≤2 and postoperative PTH (P = .257) or serum calcium levels (P = .950). Moreover, with regard to secondary endpoint, ICG correctly identified PGs in 98.3% of cases. ICG score was not affected by age, gender, duration of operation, or thyroid gland pathology. No allergic reactions attributed to ICG administration were observed.

CONCLUSION

The intra-operative ICG staining scoring system did not predict 24-hour postoperative PTH and serum calcium levels. However, this modality may assist in intra-operative PG identification during a total thyroidectomy.

Comparing LigasureTM Exact dissector with other energy devices in total thyroidectomy: a pilot study

Background

Hemostasis is fundamental in thyroid surgery. The aim of this randomized active comparator-controlled study was to compare the effectiveness of Ligasure^TM Exact to previously existing sealing devices in patients undergoing thyroidectomy.

Methods

A total of 180 patients were randomly allocated into 4 groups according to the hemostatic device used: Focus Harmonic Scalpel^® (FHS), Ligasure^TM Small Jaw (LSJ), Thunderbeat^® (TB), and Ligasure^TM Exact (LE). We recorded epidemiologic and biochemical data, operative difficulty, postoperative vocal alteration and pain, complications, operating time, grams of gland excised per minute, and hospitalization.

Results

Differences (P<0.001) were observed concerning duration of surgery, operative difficulty and quantity of gland removed per minute. Concerning duration of surgery it is shorter for LE followed by TB and then by both FHS and LSJ. Concerning the quantity of thyroid removed per minute LE leads, followed by FHS and TB. The least amount of gland removed per minute is by LSJ. Finally, operative difficulty was less for LE, while it was equal for all other three devices.

Conclusions

Energy devices are now frequently used in thyroidectomy. Comparing these devices seems to qualify them as equal concerning post-operative complications, hemostasis, and acute inflammatory reaction. However, Ligasure^TM Exact Dissector seems to have better results concerning duration of surgery, quantity of thyroid tissue removed per minute and intraoperative difficulty.

Should total thyroidectomies be performed by high-volume endocrine surgeons? A cost-effectiveness analysis

PURPOSE

The increased experience of a thyroid surgeon reduces the risk of postoperative complications. However, whether it is also cost-effective is currently unknown. The aim of the present study was to compare cost-effectiveness of high-volume (HVS) with low-volume surgeons (LVS) when performing a total thyroidectomy.

METHODS

This was a retrospective study, comparing the mean cost of a total thyroidectomy per patient, between HVS and LVS. This included the cost of surgical procedure and pre- and post-operative inpatient hospitalization. A threshold of 25 thyroidectomies/year was used to discriminate between HVS and LVS.

RESULTS

Four-hundred and forty-one patients were classified into HVS and 342 into the LVS group. With regard to surgical complications, higher rates of temporary hypoparathyroidism and endangered airway were observed in the LVS than in the HVS group. The estimated total cost per patient was higher in the LVS compared with the HVS group [€1721 ± 396 ($1910 ± 439) versus €979 ± 68 ($1086 ± 487); p < 0.0001]. This cost remained higher when sub-analysis was performed for each surgical stage, involving either surgical procedure or pre- and post-operative inpatient hospitalization. Differences between LVS and HVS mainly involved the cost in surgical procedure (23% attributed to occupation of the operating room) and postoperative inpatient hospitalization (45% of the total thyroidectomy cost).

CONCLUSION

Total thyroidectomy performed by a HVS seems to be cost-effective compared with the one conducted by LVS. This is mostly attributed to the lower rates of surgical complications, such as postoperative hypoparathyroidism and airway obstruction.

Parathyroid cysts: A review of 359 patients reported in the international literature

BACKGROUND

Parathyroid cysts are lesions that represent 1-5% of neck masses. They are subdivided into two categories: functioning and non-functioning.The aim of the present review is to give a detailed account of all reported cases of parathyroid cysts in the literature and to analyze statistically the available data.

METHODS

A bibliographic research was performed from 1905 until 2016. A database with the patients' characteristics was made and analyzed statistically.

RESULTS

A total of 218 articles were found, reporting 359 cases of cysts. Mean age of patients was 49.24 y/o and the male/female ratio was 1:1.85. The most common locations were left thyroid lobe (113/358 patients, 31.6%), and superior mediastinum (69/358 patients, 19.3%), while the most common symptoms were neck mass (148/355 patients, 41.7%), compressive symptoms (73/355 patients, 206%) and hyperparathyroidism (62/355 patients, 17.5%). Non-functioning cysts were more frequent (220/357 patients, 61.6%). Regarding dimensions, mean diameter was 4.88 cm. Ultrasound and FNA are used for their diagnosis, while cystic fluid analysis may help the differential diagnosis. Recurrences were mentioned in 27/97 patients (27.8%) with available data. No deaths due to parathyroid cysts were mentioned in the literature.

CONCLUSION

Parathyroid cysts should be taken into consideration in case of parathyroid dysfunction or asymptomatic neck mass. The surgeon's careful manipulations on the cyst are crucial for a definitive treatment.

PARATHYROID FUNCTION AFTER TOTAL THYROIDECTOMY: A RANDOMIZED CLINICAL TRIAL CONCERNING THE INFLUENCE OF THE SURGICAL TECHNIQUE

OBJECTIVE

Thyroidectomy impairs parathyroid function, even if it does not necessarily lead to postoperative clinical hypocalcemia. This study was prospective and evaluated the parathyroid hormone (PTH) function in nonclinically symptomatic patients after total thyroidectomy performed by two different techniques.

METHODS

Prospective randomized clinical trial including 269 patients undergoing classic or harmonic scalpel total thyroidectomy. Pre-operatively and at 48 hours, biochemical analysis was performed. Simultaneously, a sodium bicarbonate test (SBT) was performed.

RESULTS

Calcium and PTH were altered for both groups ( P<.001). During SBT at 3 minutes after infusion, PTH rose and reached its maximum for both groups ( P<.001) and then decreased at 5 minutes ( P<.001 and P = .004) and at 10 minutes ( P = .006 and P = .043) before returning to baseline levels. At 5 and 10 minutes of the SBT, some differences were observed between the groups. The difference in clinically obvious parathyroid dysfunction between groups was not significant, but there was a difference in the peak PTH levels after bicarbonate stimulation. Similarly, total secretion during the test, as well as total secretion for the first 10 minutes, was practically the same for the two groups. Additionally, partial subclinical postoperative hypoparathyroidism was clearly more common in the harmonic scalpel thyroidectomy group ( P<.001).

CONCLUSION

SBT demonstrated more impairment in the harmonic scalpel group, as parathyroid function was altered after thyroidectomy.

ABBREVIATIONS

HSTT = harmonic scalpel total thyroidectomy PTH = parathyroid hormone SBIT = sodium bicarbonate infusion test.

Concurrent appendiceal and umbilical endometriosis: a case report and review of the literature

INTRODUCTION

Endometriosis affects 3 to 10 percent of women of reproductive age. Most of the time it involves the pelvis; however, sites of endometriosis have been reported almost anywhere in the body. Appendiceal and primary umbilical endometriosis are considered rare loci, making accurate diagnosis elusive. Here we present the case of a 46-year-old woman with concurrent appendiceal and umbilical endometriosis.

CASE PRESENTATION

A 46-year-old Greek woman presented with a large mass in the lower abdomen adhering to the surrounding organs. She reported recurrent lower abdominal and pelvic pain and the presence of a dark-blue hard nodule at the umbilicus. She had no previous medical, surgical or gynecological history. Her physical examination and laboratory test results were without any significant findings. The laparotomy revealed a fibromatose uterus adhering to the rectum and a urinary cyst and a palpable mass in the vermiform appendix. A hysterectomy and an appendectomy were performed. The umbilical mass was also excised. Pathology revealed endometriosis of the umbilicus and the appendix. The postoperative period was uneventful and she was discharged.

CONCLUSIONS

Endometriosis, although rare, should always be considered in women of reproductive age, presenting with cyclic pain. The diagnosis is, most of the time, difficult and requires a high degree of clinical suspicion. The clinical doctor should be aware that endometriosis can sometimes be multifocal, thus a thorough investigation is required in all cases.

Condylomata acuminata within perianal fistulae tracts: report of two cases

The commonest sights of appearance of condylomata acuminata are in the genital and anal regions. Herein we present two cases of condylomata within perianal fistulae tracts, resulting in recurrence in one case and a malignant-like tumour in the second. To our knowledge, these are the first cases reported in the literature.

Surgical management of rectal prolapse

PURPOSE

Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Full-thickness rectal prolapse, mucosal prolapse and internal prolapse are three different clinical entities, which are often combined and constitute rectal prolapse. The aim of the study is to present our experience in the surgical management of rectal prolapse.

METHODS

In a 6-year period (2004-2010), 27 patients were surgically treated for rectal prolapse. The majority of patients were women (25 women, two men) and their mean age was 72.36 years. The operations performed were two Delorme's procedures, five STARR (Stapled TransAnal Rectal Resection), 14 Wells procedures, two Wells combined with Thiersch, one Altemeier, one sigmoid resection combined with Wells and two Thiersch.

RESULTS

An emergency sigmoidostomy was performed on a patient after Wells operation due to obstructive ileus. One death occurred on the 5th postoperative day due to pulmonary embolism. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation and one in a patient after Thiersch technique. The great majority of patients are completely relieved of symptoms.

CONCLUSIONS

The application of different modalities in the treatment of rectal prolapse is attributed to the fact that cause, degree of prolapse and symptoms, vary from one patient to another. Successful approach depends on many factors, including the status of a patient's anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient.

Rectal endometriosis: a case report

We present the case of a 45-year-old female patient who was admitted with a history of pelvic pain, constipation, and dysmenorrhea. CT scan and u/s images revealed cholelithiasis, benign nodular hyperplasia of segment IV of the liver and uterine fibromyoma. During laparotomy, firm adhesions between the posterior wall of the uterus and the rectum were found and the incisional biopsy reveals an undifferentiated adenocarcinoma. Then, total resection of the uterus was performed with en block resection of the adherent part of the rectum and part of the posterior wall of the vagina. The final histopathological report showed the presence of uterine fibromyoma, nodular hyperplasia of the liver and rectal endometriosis without any sign of malignancy. The patient after 5 years of follow up remains healthy. Rectal endometriosis represents an uncommon localization of pelvic endometriosis where the symptoms and clinical findings are non-specific making the definitive preoperative diagnosis difficult. Endometriosis should be included in the differential diagnosis of chronic pelvic pain in combination with defecation disorders in female patients of reproductive age.