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PubMed1996

Enterocele revealed by simultaneous evacuation proctography and peritoneography: does "defecation block" exist?

OBJECTIVE: Pelvic floor weakness may allow prolapse of the bowel into the rectogenital space, forming an enterocele. Enteroceles are believed to obstruct defecation by rectal compression and are therefore considered an abnormal finding on evacuation proctography. With a technique combine evacuation proctography and peritoneography, we prospectively studied constipated patients to reveal the pelvic peritoneal recesses during evacuation and to determine if enterocele actually impairs rectal emptying. SUBJECTS AND METHODS: Fifty constipated patients were studied prospectively, Using 20 ml of water-soluble contrast medium, we performed peritoneography, then evacuation protography with 120 ml of intrarectal paste. Lateral evacuation and posteroanterior stress views were analyzed by computerized video capture. Anatomic features and functional measurements of rectal emptying were noted. Posteroanterior views were compared with views in 31 subjects undergoing peritoneography for investigation of groin pain. RESULTS: Technical failure in three patients left 47 for analysis. A deep rectogenital pouch was seen in 36 patients (77%). Of these, 12 (58%) contained viscera that formed an enterocele, but the remaining 15 patients (42%) showed no visceral filling. Most pouches were apparent only during straining (31 cases, 86%). Peritoneal descent was greater than in controls (p < .0001), of whom only three had small rectogenital pouches. Patients with enterocele were compared with those who had a rectogenital pouch but no visceral filling and those who had no pouch. Standard anatomic measurements by evacuation proctography were not significantly different, but patients with enterocele evacuated more rapidly (p = .008) and completely (p = .021) than did the other two groups. CONCLUSION: Combined evacuation proctography and peritoneography is a new technique to diagnose pelvic hernias that occur during evacuation. This technique has shown that a deep rectogenital pouch is common in constipated patients and that just over half such pouches fill with viscera. However, because an enterocele does not impair rectal evacuation, this proctographic finding should be interpreted with caution.

Adolescent↗
PubMed2006

Anatomy of the sigmoid colon, rectum, and the rectovaginal pouch in women with enterocele and anterior rectal wall procidentia.

This study describes the anatomy of the rectovaginal pouch, the sigmoid colon, and rectum in women with posterior enterocele and anterior rectal wall procidentia. The anatomy of rectovaginal pouch, sigmoid colon, and rectum was described in 36 women with an enterocele (group A) and compared with those of 43 women (group B) without pelvic organ prolapse. Women with previous incontinence or prolapse surgery were excluded. The mean age in group A was 58 years (40-75) and in group B 35 years (19-64; P < 0.001). There were 15 nulliparas in group B. Nine women in group A had an internal anterior rectal wall procidentia, and one woman had an external anterior rectal wall procidentia. In group A, the rectovaginal pouch was significantly deeper, the sigmoid mesocolon at S1 shorter and showed more often a straight course (P < 0.05). These characteristics (termed "grande fosse pelvienne") were present in 23 women (64%) in group A and in 6 (14%) in group B, three of the latter were young nulliparas (P < 0.001). Age, parity, menopausal status, body mass index, constipation, and varicose veins were not associated with a grande fosse pelvienne. The typical anatomy in women with an enterocele and anterior rectal wall procidentia was a sigmoid colon with a straight course and a short mesentery at S1 and a rectovaginal pouch that covered more than half of the vaginal length. It may be a congenital condition and important in the development of an enterocele and rectal wall procidentia.

Adult↗
PubMed1995

Simultaneous defecography and peritoneography in defecation disorders.

UNLABELLED: A number of physiologic and radiologic investigations are used in investigating defecation disorders. Defecography is one important part of these investigations. However, a correct diagnosis of an enterocele is sometimes difficult despite use of contrast media in the rectum, vagina, and small bowel. PURPOSE: This study was undertaken to ascertain if it was technically possible to perform simultaneous defecography and peritoneography in an effort to improve the diagnostic possibilities in patients with defecation disorders. METHODS: Twelve patients with defecation disorders and an unexplained widening of the rectovaginal space at defecography were investigated. Contrast medium was introduced intraperitoneally, after which conventional defecography was performed. RESULTS: All investigations were carried out without complications and demonstrated the peritoneal outline in all patients. Simultaneous defecography and peritoneography differentiated between an enterocele and a pathologically deep pouch of Douglas--a peritoneocele. Three types of peritoneocele were visualized: vaginal peritoneocele, septal peritoneocele, and rectal peritoneocele with or without enterocele. Combinations of the three types were also found. Eight of the 12 patients had rectal intussusception or rectal prolapse. All of these eight patients had a rectal peritoneocele. CONCLUSIONS: Simultaneous defecography and peritoneography can be performed without technical difficulties or complications. Peritoneal outlines and pouches can, therefore, be studied directly during the act of defecation. An unexplained widening of the rectovaginal space at defecography can be clarified as a peritoneocele, with or without an enterocele. Peritoneocele can be of three different types: rectal, septal, or vaginal.

Aged↗
PubMed1992

Cytohistologic assessment of antitumor effects of intraperitoneal hyperthermic perfusion with mitomycin C for patients with gastric cancer with peritoneal metastasis.

For 15 patients with refractory gastric cancer and peritoneal metastasis, intraperitoneal hyperthermic perfusion (IPHP) using mitomycin C combined with extensive surgery was prescribed. The antitumor effects were assessed cytohistologically in pre-IPHP and post-IPHP specimens of the abdominal effusion and peritoneal tissue. Gastric cancer cells in the abdominal effusion and/or lavage vanished from post-IPHP peritoneal exudate obtained from the pouch of Douglas. Peritoneal tissues from nine patients were harvested just after the IPHP treatment. All the nuclei of cancer cells were pyknotic in three of nine patients, and two of these three patients are alive with no local recurrence; one patient died of hepatic metastasis. In the remaining six patients, four with preoperative ascitic effusion and positive post-IPHP histologic findings died of peritoneal, intraabdominal, and pericardial metastases. The other two had some residual microscopic foci in the subperitoneal deep layer; one patient died of pleural recurrence, and the other is alive with no evidence of recurrence 42 months after the IPHP. Among the other six patients, whose post-IPHP peritoneal tissues were not available because of disappearance of disseminating foci as a result of the IPHP, two are living with no recurrence and, of the remaining four patients, three died of hepatic and intraabdominal metastases and the other one died of other causes. The histologic findings are suggestive of the following: (1) uniform heat and drug distribution in the abdominal cavity with IPHP treatment, except for an area adjacent to the inflow point of the perfusate; and (2) limited penetration of heat and drug through the subperitoneal layer. Thus, IPHP treatment results in complete destruction of cancer cells in the abdominal effusion and on and just beneath the peritoneum.

Adult↗
PubMed1982

The efficacy of peritoneal lavage at elective abdominal operations.

Human serum albumin microspheres of 1 micrometer diameter labelled with technetium-99 m were evaluated as a model for bacteria in two animal species. Peritoneal lavage recovered comparable amounts of an inoculum of microspheres and simultaneously instilled Escherichia coli. A prospective study was undertaken of 38 patients undergoing elective abdominal operations. Three lavages, each of 500 ml normal saline, were used. Over 80 per cent of the saline was recovered in 37 of the 38 patients with a median of 93 per cent. Recovery of microspheres was assessed from above the spleen, from Morison's pouch and from the pouch of Douglas. There was no difference in the recovery rates from the three sites of placement but significantly fewer microspheres were recovered via a right subcostal incision (median 59 per cent) compared with an upper midline incision (median 91 per cent).

Abdomen↗
PubMedDate not supplied

Cul-de-sac insufflation: an easy alternative route for safely inducing pneumoperitoneum.

Since 1977, routine cul-de-sac insufflation to achieve a pneumoperitoneum for laparoscopy was performed on 350 women under local anesthesia. A van Schie/van Lith intrauterine tenaculum, used together with a self-retaining Trelat speculum, guaranteed maximum stretching of the posterior vaginal fault and fixation of the anteflexed uterus necessary for an accurate 1-cm deep penetration of a pneumoperitoneum needle into the cul-de-sac. The correct position of the tip of the needle was determined precisely by means of two manometers. The failure rate in the first study of 195 procedures was 3.6% and that in the following 155 cases was 1.9%. There were no serious operative complications. The authors recommended the cul-de-sac insufflation approach for inducing pneumoperitoneum as the technique of choice.

Douglas' Pouch↗
PubMed1980

Cul-de-sac insufflation to induce pneumoperitoneum: an analysis of rare problems.

Since 1977, cul-de-sac insufflation has been used to achieve pneumoperitoneum for laparoscopic sterilization of 570 women. The authors have previously published findings on 350 of these women (Int J Gynaecol Obstet 17(4):375, 1980), reporting technical failure rates of 3.6% and 1.9% for a series of 195 and 155 women, respectively. The failure rate for the latest series of 220 women declined to 1.4%. Reasons for this lower rate and recurring causes of the failures are given, and recommendations for the use of cul-de-sac insufflation for inducing pneumoperitoneum are suggested.

Douglas' Pouch↗
PubMed2005

Transvaginal sonographic features of peritoneal carcinomatosis.

OBJECTIVES: Peritoneal carcinomatosis involves the dissemination of intra-abdominal tumor tissue often associated with gynecological malignancies. The objective of this study was to describe the transvaginal sonographic appearance of this condition. METHODS: The data of 60 patients with surgically and histologically proven peritoneal carcinomatosis were analyzed. Transvaginal sonograms performed within 7 days of admission to the operating theater were re-evaluated in order to identify the sonographic features associated with peritoneal carcinomatosis. RESULTS: Carcinomatosis was revealed in 53/60 cases (88%) by the presence of hypoechoic nodules attached to the peritoneum and visible on transvaginal sonography (TVS). The pouch of Douglas was the site most frequently involved. Power Doppler sonography showed the presence of blood vessels in 48 (91%) of these metastases. Ascites was found in 50 (83%) women. An adnexal mass suggestive of being the primary tumor was present in only 41 women (68%). CONCLUSIONS: Peritoneal carcinomatosis has typical features on TVS and, in the vast majority of cases, its genital origin can be correctly hypothesized. Power Doppler sonography strengthens the diagnosis by showing vascularity of the peritoneal implants. In a patient with a known pelvic malignancy or whenever peritoneal carcinomatosis is suspected, TVS can give useful information in order to better assess the presence and extension of metastatic nodules within the abdominal cavity.

Adult↗
PubMed1999

Ovarian endometrioid-like yolk sac tumor treated by surgery alone, with recurrence at 12 years.

We describe the case of a stage Ia endometrioid-like yolk sac tumor (YST) of the ovary, which was originally misdiagnosed as a malignant struma ovarii and not treated with adjuvant chemotherapy. After 12 years, a contralateral dermoid cyst was excised along with a small omental nodule of partially necrotic and calcified endometrioid-like YST. No tumor was detected in several other biopsy specimens, and a peritoneal lavage was negative for tumor cells. Since there was no evidence of remaining tumor and the serum alpha-fetoprotein (AFP) level was normal after the second operation, the patient was followed. Serial serum AFP levels remained normal for 4 months. At a second-look laparotomy after 4 months, a small tumor nodule was removed from the cul-de-sac. Postoperatively, the patient received three cycles of BEP chemotherapy. The long disease-free interval after the first operation in spite of the presence of occult spread to the omentum and to the pouch of Douglas in this case indicates that some endometrioid-like YSTs may have an indolent course. The present case underscores the importance of careful surgical staging and of long-term follow-up in cases of primitive germ cell tumors of the ovary.

Adult↗