Case report of an intracaval leiomyomatosis 10 months after complete hysterectomy

•

Intravenous leiomyomatosis within the vena cava can spread rapidly as far proximally as intracardially.

•

Intravenous leiomyomatosis can be removed bluntly through cavotomy.

•

Sternotomy can be avoided, reducing the surgery to a laparotomy.

Introduction

Intravenous leiomyomatosis (IVL) is a rare smooth muscle tumor, usually found in women with tumors of the reproductive organs, such as uterus myomatosous. Surgically, this case belies the call for sternotomy and two-stage surgery in caval IVL extending to the right atrium: we suggest one-stage median laparotomy as a minimal procedure with maximal benefit.

Presentation of case

We present the case of a 60-year-old postmenopausal woman with suspected intravenous leiomyomatosis of the right internal iliac vein. The patient had undergone hysterectomy and bilateral adnexectomy for uterus myomatosous in September 2015, where an IVL limited to the veins of the uterus and the right adnex had been diagnosed. No further medical treatment had been implemented. IVL of the inferior vena cava was diagnosed when a CT scan of the abdomen was performed due to an infected abdominal seroma in June 2016. Although histologically benign, we found this case of IVL to be clinically aggressive because of its expansion to the heart. This may lead to thromboembolic complications (e.g. pulmonary embolism) or signs of right sided cardiac failure. The patient was asymptomatic, but because of the extension of the intracaval thrombus to the heart, we decided to operate and performed thrombectomy via a median laparotomy. The patient left the hospital shortly after on newly started oral anticoagulation.

Discussion

For caval IVL without intracardiac attachment, the extraction via laparotomy without sternotomy is the treatment of choice. It calls for an interdisciplinary approach and careful surgical planning.

Conclusion

There is no inherent need for sternotomy in IVL extending to the right atrium. A one-year follow-up with sonographic control is advised. Medium term oral anticoagulation should be considered.

This work has been reported in line with the SCARE criteria Agha et al. (2016). The SCARE Statement: Consensus-based surgical case report guidelines. Agha RA, Fowler AJ, Saeta A, Barai I, Rajmohan S, Orgill DP; SCARE Group. Int J Surg. 2016 Oct;34:180-186 [1].

Swelling of the right thigh for over 30 years-The rare finding of a De Garengeot hernia

•

Inguinal/femoral swelling can obtain the appendix.

•

De Garengeot hernia needs to be considered as differential diagnosis in all femoral hernia.

•

A femoral hernia in a woman can obtain the appendix in an open processus vaginalis.

•

Sonography is a valid diagnostic tool for De Garengeot hernia.

INTRODUCTION

Femoral hernias may – in some rare cases – contain the appendix, a phenomenon called de Garengeot hernia. It is usually an incidental finding in hernia repair. We found our case to be of interest because of the long standing femoral swelling before peracute appendicitis led to its removal.

PRESENTATION OF CASE

We present the case of a 71-year-old woman with a swelling of the right medial thigh for over more than 30 years. When the swelling suddenly grew in size and became tender, she was referred to our emergency department. Sonographically as well as clinically a femoral hernia was diagnosed. Intraoperatively, the appendix was found and open appendectomy as well as a hernioplasty was performed.

DISCUSSION

Open appendectomy is an elegant and safe procedure to repair a long standing de Garengeot hernia. Most case reports call for extensive diagnostics such as CT scan etc. We found a sonography of the femoral region to be conclusive.

CONCLUSION

Apart from the inherent risk of sudden incarceration in hernias, De Garengeot hernias can also develop peracute appendicitis years after their formation. This differential diagnosis needs to be taken into consideration in patients presenting with the clinical signs of a femoral hernia.

[Effect of diabetes-psychosomatic group education on metabolic control and coping with disease by insulin-dependent diabetic patients]

Even though cognitive education programs are essential for the treatment of diabetics, long term efficacy often seems to be poor. Problems of coping with illness could be the reason for a lack of transfer of knowledge into daily practice. Small discussion groups with the aim of modifying attitudes towards illness might be a good possibility to face this problem. 54 IDDM, HbA1 10.7 +/- 2.3% (median +/- SD) absolved our 5-day education program for outpatients, in which daily group sessions (90 min), supervised by a group-therapist, were integrated. Follow-up sessions took place after 1, 4 and 8 months. The efficacy was measured by HbA1 and different questionnaires on diabetologic knowledge, life satisfaction (FLZ) and complaints (BL). 4 months after the education program HbA1 had decreased to 9.0 (median +/- SD) and remained stable within small range during the rest of the study-period. Diabetologic knowledge increased from 70% (median +/- SD) to 87% (median +/- SD) 1 month after the education and remained stable during the rest of the study-period. Complaints decreased within one month from a level above average somatic illness to the normal level for healthy subjects. However, in regard to their life satisfaction our patients were significantly less satisfied concerning their health, whereas family life and friendship were declared to be more satisfying (after 8 months). We believe that more intensive communication in the family (encouraged by the group-therapy) and parallel more critical attitudes towards illness lead to this results. As basic elements for long term modification of illness behaviour these emotional aspects seem to be essential.