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PubMed1996

Trauma ultrasound workshop improves physician detection of peritoneal and pericardial fluid.

Hemoperitoneum represents a major indication for surgical intervention after trauma. To improve the ability of surgical residents and trauma physicians to detect intraperitoneal and pericardial fluid using ultrasound as a diagnostic modality, we conducted a focused trauma ultrasound workshop consisting of discussion of ultrasound physics, demonstration of instrumentation, review of pertinent literature, videotaped demonstration, and "hands-on" teaching of the skills utilizing live patient models. The ultrasound probes were placed in four standard locations--right and left upper quadrants, epigastrium, and Pouch of Douglas. Skills acquisition was tested by pre- and postworkshop performance on 12 sonograms (3 for each location, 6 were positive for fluid). Thirty physicians (21 residents and 9 staff: Group I) who attended the workshop were compared to 30 matched controls (Group II). The results (means +/- SD) were as follows (R = number right, I = number of "indeterminate," W = number of wrong responses out of 12, *P < 0.05 compared to Group II): [Table: see text] False positive (%) and false negative (%) decreased from 12.9 +/- 1.5 to 8.9 +/- 5.3 and 15.0 +/- 10.4 to 5.0 +/- 5.2, respectively, in Group I but did not change in Group II. Postworkshop ability to detect fluid was significantly (P < 0.05) improved, with no major differences between residents and staff. Our data suggest that these workshops can significantly improve the skills of nonradiologists in sonographic identification of pericardial and intraperitoneal fluid and should therefore be considered an essential component of ultrasound training for trauma physicians.

Ascitic Fluid↗
PubMed1983

[Appendectomy - tenets of a century].

A small hospital reports on the results of 1302 appendectomies: all degrees of morbidity of the appendix and all patient ages are represented. There were only 2 deaths (0.15%), which also illustrates the very satisfactory success rate in the 16 "urgent early relaparotomies" (only 1 of 11 patients died). Richly demonstrated by case reports, it deals with diagnostic, indicative, and intraoperative problems and finally broaches the subject of "suppurative pylethrombophlebitis" secondary to acute appendicitis, including the question about its fateful course.

Abscess↗
PubMedDate not supplied

Herniography.

Herniographic examinations were performed on more than 4,000 patients. The method was found to be of great value in patients with obscure symptoms in the groin or pelvis. Herniography shows not only hernial sacs but also the general condition and tissue strength of the inguinal part of the abdominal wall. The different types of hernias have different signs that, as a rule, allow an exact diagnosis. The pelvic floor and the pouch of Douglas can always be evaluated. Young athletes with severe symptoms in the groin, in most instances, were found to have some type of hernial rupture and often osteochondritis in the pubic symphysis as well. In women, the clinical diagnosis of hernia is often difficult. Herniography was of great value in these patients.

Adult↗
PubMed1998

Pelvic floor procedures produce no consistent changes in anatomy or physiology.

PURPOSE: Postanal repair was designed to restore both anatomy and function of the anal canal in neurogenic fecal incontinence. In most series, the degree of continence is improved in fewer than 50 percent of patients. Adding anterior levatorplasty and sphincter plication (total pelvic floor repair) is claimed to improve functional results. We performed a randomized trial comparing postanal and total pelvic floor repair for neurogenic incontinence. METHOD: Twenty female patients were studied. All had Type D incontinence (Parks and Browning). Anal manometry, defecography, and grading of the degree of continence were repeated 12 weeks after surgery to assess changes in clinical, manometric, and radiologic parameters. Statistical analysis was done using Wilcoxon's signed-rank test and Wilcoxon's two-sample test. RESULTS: Continence improved in eight patients. Differences among clinical, manometric, and radiologic data were not statistically significant. CONCLUSION: Pelvic floor repair procedures produce no consistent changes in anatomy or physiology. Clinical improvement is caused by creation of a local stenosis or by the placebo effect rather than by improvement of muscle function.

Adult↗
PubMed1990

Early detection of ectopic pregnancy by transvaginal ultrasound.

Transvaginal (TVU; 19 patients) and transabdominal ultrasound (TAU; 24 patients) were compared in their ability to visualize an ectopic pregnancy. The direct visualization of ectopic pregnancy (EUP) was 25% with TAU and 94.7% with TVU. All women had a proven EUP in laparoscopy. TAU approach showed a significant inferiority (P less than 0.02) and TVU a superiority (P less than 0.08) in comparison to clinical examination. 83% of 43 women had spotting. Nonspecific signs for EUP like fluid in the pouch of Douglas was seen in 20.9%. Thin endometrium was seen in 6.9%, in 37.2% the thickness of endometrium was under 10 mm, in 55.8% more than 10 mm. An intrauterine pseudogestation sac was detected in 6.9%, corpus luteum formation in 37.2%.

Adult↗
PubMed1984

Rectal procidentia in elderly and debilitated patients. Experience with the Altemeier procedure.

The term "rectal procidentia" implies circumferential full-thickness descent of the rectum through the anal sphincter. This condition occurs because of several structural and anatomic changes and offers a challenge in its management. There are over 50 different surgical procedures described to correct this condition. Unfortunately, when it occurs in the elderly and infirm, there is very little that can be done. Such poor-risk patients should be managed with a perineal repair as described by Altemeier. The purpose of this article is to review our results and experiences with Altemeier's procedure in managing rectal procidentia in elderly and debilitated patients.

Age Factors↗
PubMed1993

Evaluation of laparoscopy and endocervical swab in the diagnosis of Chlamydia trachomatis infection of the female genital tract.

A group of 60 consecutive women admitted to the gynaecology department of Eastbourne District General Hospital for pelvic pain were entered into this study. Evidence of C. trachomatis infection of the genital tract was investigated by detection of chlamydial lipopolysaccharide antigen in the peritoneal fluid collected from the pouch of Douglas during laparoscopy and in the endocervical swab. The test used was an Enzyme-Linked Immunosorbent Assay (ELISA). Peritoneal fluid was positive in 11 subjects (18%, P < 0.05), endocervical swab was positive in 3 (5%, P < 0.05). The difference was statistically significant (P = 0.01, two tailed test at 1% level). Ten women with a positive ELISA on the peritoneal fluid had a negative cervical swab, 2 women with a positive cervical swab had negative peritoneal fluid and in only one woman were both cervical swab and peritoneal fluid positive.

Adult↗
PubMed1993

Bile leakage after laparoscopic cholecystectomy demonstrated with 99mTc-PMT hepatobiliary scintigraphy.

A 41-year-old woman underwent laparoscopic cholecystectomy for the treatment of gallstone and adenomyomatosis. One month after laparoscopic cholecystectomy, hepatobiliary scintigraphy was performed with 99mTc-Sn-N-pyridoxyl-5-methyltryptophan (PMT) to evaluate the presence of a bile leak and/or other complication. A biliary extravasation was noted in the left upper quadrant within 60 minutes. At five hours post injection, a progressive accumulation of 99mTc-PMT was noted in the lesser sac, the right and left paracolic gutter and in the pouch of Douglas. A diagnosis of biliary leakage was made. The patient underwent exploratory laparotomy to repair the leak from the cystic duct stump.

Adult↗
PubMed1997

Laparoscopic douglasectomy in the treatment of painful uterine retroversion.

BACKGROUND: One of the etiologies of pelvic pain in women, often unrecognized, is the Masters-Allen syndrome, which was described in 1955 as the "universal joint cervix" syndrome. It has the following three elements: (1) etiology: obstetrics-related trauma; (2) clinical findings: uterine retroversion with hypermobile cervix following elongation or desinsertion of the uterosacral ligaments; (3) anatomy: visualization of a tearing of the posterior serosa and subperitoneal fascia of the ligamentum latum. METHODS: Forty-one laparoscopic Douglasectomies with uterosacral ligamentopexy were performed in the department of Gynecology at the University Hospital of Caen during the period between 1990 and 1995 in patients with painful retroverted uterus. The patient selection was made thanks to the "pessary test." The surgical endoscopic procedure, identical to the operation first promoted by Jamain and Letessier in 1976 by laparotomy, is described. RESULTS: Total pain relief was experienced by 31 patients (75%) and partial relief by five patients (5%). Two main complications occurred, requiring one laparotomy (bleeding from a pelvic varicose vein with a concomitantly occurring breakdown of the washing-aspiration system) and one second laparoscopy at day 15 (one case of hematoma below the peritonization revealed by pain). Twenty-three women became pregnant again, and had normal deliveries except for two cesareans, with no recurrence of pain. Douglasectomy is compared to alternative techniques in the literature. Other indications for Douglasectomy are discussed. CONCLUSION: Douglasectomy is the only definitive procedure for restoring normal anatomy of the pelvic floor in case of painful uterine retroversion occurring in a setting of Masters-Allen syndrome. Additionally, it provides for pathological analysis of the excised peritoneum. The results of this procedure are excellent when the indication is correctly set, particularly as concerns positive pessary testing.

Adult↗
PubMed2003

Prevention of genital prolapse following Burch colposuspension: comparison between two surgical procedures.

Our objective was to evaluate the efficacy of cul-de-sac obliteration in preventing pelvic floor anatomical defects formation following Burch colposuspension. We evaluated 441 patients who had undergone Burch colposuspension. The patients were divided into two groups: group A (132 patients) who underwent Burch colposuspension only, and group B (309 patients) who had had a concomitant cul-de-sac obliteration. Cul-de-sac obliteration was performed using two different techniques, the Moschocowitz procedure in 131 patients, and approximation of the sacrouterine ligaments in 178 patients. The follow-up period was 8.6 years (range 3-16). In total we found 43/441 (9.7%) postoperative anatomical defects. Obliteration of the cul de sac significantly (P<0.0001) reduced the formation of anatomical defects compared to Burch colposuspension. In a comparison of the two surgical procedures for cul-de-sac obliteration, the approximation of the sacrouterine ligaments was significantly more effective than either the Moschcowitz procedure (P<0.001) or the Burch colposuspension alone (P<0.001). The Moschcowitz procedure reduced the formation of anatomical defects to 15/131 (11.4%) compared to Burch colposuspension only (25/132; 18.9%), but statistically the difference was insignificant. The time of anatomical defect detection was significantly reduced after cul-de-sac obliteration: 2 years 6/25 (24%) in group A compared to 1/8 (5.5%) in group B (P<0.01). After 5 years the detection rate was 64% (16/25) and 22.2% (4/18) respectively (P<0.01). It was concluded that cul-de-sac obliteration using approximation of the sacrouterine ligaments significantly reduced the incidence of anatomical defect formation following Burch colposuspension. A long follow-up period is needed to evaluate the truce incidence.

Douglas' Pouch↗
PubMedDate not supplied

Diagnosis of adnexal torsion in the third trimester of pregnancy: a case report.

The diagnosis of adnexal torsion is difficult to establish on the basis of symptoms, physical findings, or radiologic techniques. If possible, in pregnancy the diagnostic workup should avoid any risk of drug administration, and the indication for a surgical intervention needs to be severe. Between 10% and 20% of ovarian torsions are associated with pregnancy, but adnexal torsion in the third trimester is rare. We present the case of a 22-year-old female presenting with a sudden onset of severe right lower quadrant abdominal pain associated with nausea and vomiting. The presumptive diagnosis was appendicitis. Transvaginal sonography showed some free fluid in the pouch of Douglas, but could not define the accurate diagnosis. In transabdominal ultrasound, a predominantly hyperechogenic mass containing small cysts was found in the right lower abdomen. No blood flow within the mass was detected with color and power Doppler sonography. With ultrasound, the anatomic relation of the mass could not be precisely identified. Magnetic resonance imaging clearly delineated the mass, which was due to enlargement of the right ovary, with predominately hyperintense signal containing small areas with hypointense lesions in T2-weighted images, a potential sign of hemorrhagic infarction. The mesovarium was hyperintense in T2-weighted images and also enlarged. The left ovary seemed to be normal. Due to the displacement of the ovaries in the second and third trimesters, the diagnostic workup is very largely restricted when using transvaginal ultrasound. Especially in pregnancy, it is mandatory to obtain a reliable diagnosis to reduce any risk to the fetus. Our case report indicates that the combination of magnetic resonance imaging and Doppler sonography fulfills these requirements and allows for accurate and fast diagnosis of adnexal torsion.

Adnexal Diseases↗
PubMedDate not supplied

Right anterior subphrenic space: an important site for the early detection of intraperitoneal fluid on abdominal CT.

BACKGROUND: Small rinds of free fluid are frequently seen in the right anterior subphrenic space. Therefore, we investigated patients undergoing abdominal computed tomography (CT) to see whether early fluid collections are seen preferentially at this or any other site. METHODS: CT examinations of 59 randomly selected patients with minor or moderate quantities of free intraperitoneal fluid were analyzed. The location of the fluid was determined [subphrenic spaces, the right hepatorenal fossa (Morison's pouch), paracolic gutters, pelvis (pouch of Douglas)]. The amount of fluid in each location was subjectively quantified (none, trace, small, or moderate). RESULTS: Free fluid was seen most frequently in the right anterior subphrenic space (44/59 patients, 75%) and pelvis (43/59 patients, 73%). Eight patients had intraperitoneal fluid at an isolated location (three in the pelvis alone, two in the left subphrenic space, one in the right subphrenic space, and one in each of the right and left paracolic spaces). CONCLUSIONS: Contrary to popular belief, intraperitoneal fluid is not always seen first in the pelvis when the patient is in the supine position. Although fluid is not consistently seen first in any specific location, the subphrenic space (especially the right anterior) is a common site where small quantities of fluid may be identified.

Adolescent↗
PubMed2005

When is curative gastrectomy justified for gastric cancer with positive peritoneal lavage cytology but negative macroscopic peritoneal implant?

For gastric cancer patients who have no peritoneal seeding at a macroscopic level but positive results in the peritoneal lavage cytology (PLC), the prognostic benefit expected by surgical resection is still controversial. During the period 1975-1994 as series of 417 consecutive patients without distant organ metastases underwent surgical resection for gastric cancer that had invaded the subserosal or deeper layers of the stomach wall. Immediately after laparotomy, the pouch of Douglas was washed with 100 ml of physiologic saline solution, and the fluid was collected for cytologic examination (four slide glasses) using Giemsa and Papanicolaou staining methods. According to the macroscopic (P) and cytologic (Cyt) results, the 417 patients were classified into three groups: P(+) (n = 97); P(-)/Cyt(+) (n = 25); and P(-)/Cyt(-) (n = 295). Their 3-year survival rates after surgical resection were 4%, 24%, and 48%, respectively (p = 0.0001: P(-)/Cyt(+) vs. P(-)/Cyt(-); p = 0.0018: P(-)/Cyt(+) vs. P(+). Among the 25 P(-)/Cyt(+) patients, postoperative survival was not associated with the T stage, N stage, cellular atypism, or cluster formation but with the number of cancer cells per slide during PLC. The 3-year survival rate was 35% for the subgroup with fewer than 10 cancer cells per slide (17 patients) and 0% for the other subgroup with 10 or more cancer cells per slide (8 patients) (p = 0.017). For P(-)/Cyt(+) patients, who represent a subgroup of gastric cancer patients with an intermediate survival rate between the P(-)/Cyt(-) and P(+) patients, the number of cancer cells observed during PLC offers a potent prognostic indicator for the gastrectomy.

Adult↗
PubMed1997

Acute abdomen due to endometriosis as a diagnostic and therapeutic challenge in the treatment of acute myelocytic leukemia.

Acute abdominal pain is a frequent diagnostic and therapeutic challenge in hematologic patients. We report on the very rare case of organ endometriosis with acute abdominal symptoms in a 43-year-old female patient with AML-M5, starting 4 days after induction chemotherapy with idarubicin, ara-C, and etoposide. The patient presented with an acute abdomen with clinical findings of acute cholecystitis, subileus, and local pain in the right upper abdomen accompanied by severe diarrhea. Probably due to impaired intestinal resorption, menstrual bleeding occurred despite regular administration of lynestrenol. Ultrasound examination of the abdomen disclosed a tumor with poor echoes in the pouch of Douglas, a subcapsular splenic hemorrhage, and a thickened gallbladder wall with surrounding edema. A cystic adnex tumor was confirmed by endovaginal ultrasound. Based on history and the findings on ultrasound, an endometriosis was diagnosed, and the LHRH agonist (nafarelin) was administered nasally in combination with lynestrenol. Following this medication the abdominal pain ceased, supporting the diagnosis of endometriosis. Nasal administration of an LHRH agonist in the following cycles of chemotherapy was effective in preventing further abdominal discomfort and vaginal bleeding. LHRH agonists should be given to patients with known endometriosis before starting myeloablative chemotherapy to prevent painful hemorrhage from endometriosis.

Abdomen, Acute↗
PubMed2005

Role of pelvicography and colpocystodefecography in diagnosis of outlet obstructive constipation.

AIMS: The aim was to research the changes in pelvic floor morphology and corresponding visceras in patients with outlet obstructive constipation (OOC). PATIENTS AND METHODS: Thirty-eight patients with OOC and 12 healthy volunteers were enrolled in this study. With simultaneous pelvicography and colpocystodefecography (PCCD), including pelvicography, vaginal opacification, voiding cystography and defecography, pelvic floor morphology was observed and the anorectal angle, the level of the perineum, peritoneum and bladder were measured. RESULTS: Thirty-seven cases of internal rectal prolapse (IRP), 5 cases of rectocele (RC) and 5 cases of spastic pelvic floor syndrome SPFS were diagnosed by PCCD. 12 IRP, 4 RC and 1 SPFS were detected by common physical examination. All of these were confirmed by PCCD. Moreover, PCCD found 9 pelvic floor hernia or peritoneoceles, 6 cystoceles, 3 descending perineum syndromes and 10 uterine prolapses. Compared with controls, OOC patients had a significantly large anorectal angle during defecation, abnormal descending of the perineum at rest and during defecation, and a deep pouch of Douglas during defecation. Some patients with urinary system symptoms may have had an abnormal descent of the bladder during rest and defecation. CONCLUSION: Simultaneous PCCD has a higher positive ratio than the common physical examination in diagnosing IRP and RC, and provides information for the diagnosis of pelvic floor hernia or peritoneocele, cystocele or uterine prolapse. PCCD is helpful in the selection of a proper surgical procedure.

Adult↗