Characterising umbilical abdominal wall endometriosis as a distinct subgroup of abdominal wall endometriosis - retrospective cohort study

Abdominal wall endometriosis (AWE) is one of the rarest forms of endometriosis. Little is known about differences between umbilical AWE (U-AWE) and non-umbilical AWE (non-U-AWE) patients. This retrospective cohort study included patients treated for AWE at tertiary endometriosis centre between 2012 and 2020. Patients were divided into two groups - umbilical AWE and non-umbilical AWE.We identified 14 U-AWE and 45 non-U-AWE patients who mostly had lesions in caesarean section scar (38, 64.4%), rarely at other locations (7, 11.9%). Infertility rates for U-AWE patients and non-U-AWE patients were 57.1% and 17.8%, respectively. Concurrent or previous peritoneal endometriosis was noted in 85.7% of U-AWE and 24.4% of non-U- AWE patients. In addition, U-AWE patients and non-UAWE patients significantly differed in following: parity, number of previous caesarean sections, lesion size, prevalence of concurrent or previous deep infiltrating endometriosis, bleeding from abdominal wall, cyclic pain, continuous pain.Infertility and pelvic endometriosis were more prevalent in U-AWE patients. Our data suggests that U-AWE may be a specific marker for a patient highly prone to pelvic endometriosis and subsequent infertility. Findings suggests that clinician should consider comprehensive evaluation of U-AWE patients.

An innovative reconstruction of an enbloc resected composite giant chest and abdominal wall chondrosarcoma with 3D-composite mesh

BACKGROUND

Chest wall chondrosarcomas, although common, pose unique challenges due to their aggressive nature, rarity of abdominal wall involvement, and propensity for recurrence. We highlight the critical role of meticulous surgical planning, multidisciplinary collaboration, and innovative reconstruction techniques in achieving optimal outcomes for patients with composite giant chest and abdominal wall chondrosarcoma.

CASE PRESENTATION

A 38-year-old female patient presented with progressive left chest and abdominal wall swelling for two years; on evaluation had a large lobulated lytic lesion arising from the left ninth rib, scalloping eighth and tenth ribs measuring 13.34 × 8.92 × 10.71 cm (anteroposterior/transverse/craniocaudal diameter) diagnosed with chondrosarcoma grade 2. A three-dimensional (3D) composite mesh was designed based on computed tomography using virtual surgical planning and computer-assisted design and manufacturing technology. She underwent wide local excision and reconstruction of the chest and abdominal wall with 3D-composite mesh under general anesthesia. The postoperative condition was uneventful, with no recurrence at 12 months follow-up.

CONCLUSION

A 3D-composite mesh facilitates patient-specific, durable, and cost-effective chest and abdominal wall reconstruction.

Surgical techniques and effectiveness of laparoscopic resection of abdominal wall desmoid-type fibromatosis and defect reconstruction: a single-center retrospective analysis

PURPOSE

Although the treatment of abdominal wall desmoid-type fibromatosis (DF) has evolved over the past decades, surgical treatment remains an important approach. Previously, surgeries for abdominal DF were mostly performed by laparotomy, which involves massive dissection and significant trauma. Here, we report our single-center experience of the laparoscopic management of abdominal wall DF in young female patients.

METHODS

The clinical data of nine patients diagnosed with abdominal wall DF during January 2020-April 2022 at the Qilu Hospital of Shandong University were retrospectively analyzed. All patients underwent laparoscopic resection of abdominal wall DF and immediate abdominal wall reconstruction (AWR) with mesh augmentation via the intraperitoneal onlay mesh (IPOM) technique.

RESULTS

Laparoscopic DF resection and AWR were successfully performed in all patients. The mean operation time was 175.56 ± 46.20 min. The width of abdominal wall defect was 8.61 ± 3.30 cm. Full- and partial-thickness myofascial closure and reapproximation were performed in five, two, and two patients, respectively. The average mesh size was 253.33 ± 71.01 cm2. The total and postoperative lengths of hospital stay were 11.00 ± 3.46 and 4.89 ± 2.03 days, respectively. Tumor recurred in one patient after 20 months of the resection. Nonetheless, death, herniation, or bulging were not observed in any patient during a mean follow-up of 16.11 ± 8.43 months.

CONCLUSION

Laparoscopic resection of abdominal wall DF and immediate AWR with IPOM mesh reinforcement is safe and reliable for young female patients. Management of such patients should be decided according to the biological behavior, size, and location of tumors.

Extragonadal recurrence of benign mature teratoma in the pouch of Douglas

Laparoscopic cystectomy for mature teratomas is associated with a high incidence of intraperitoneal spillage and tumor spread; however, extragonadal recurrence of this benign tumor is rare. We hereby present an additional case of extragonadal mature teratoma that recurred in the pouch of Douglas after ovarian cystectomy. A 43-year-old Japanese woman presented with atypical genital bleeding. A 7 cm mature teratoma was detected using transvaginal ultrasonography and magnetic resonance imaging. At 26 years old, she underwent bilateral cystectomy for bilateral mature teratoma of the ovary. During laparoscopic surgery, a cystic tumor appeared in the pouch of Douglas and was firmly adhered to the surrounding tissues. Both ovaries were normal. The resected tumor was diagnosed as extragonadal, benign, mature teratoma. To avoid the extragonadal recurrence of mature teratoma, removal of tumor contents from intraperitoneal spillage by lavage should be performed at the end of surgery.

Metastatic juvenile granulosa cell tumor in abdominal wall

Juvenile granulosa cell tumor (JGCT) is an uncommon ovarian tumor. There are only a few cases in the literature that depict the cytomorphology of JGCT at the primary/metastatic site. We described the fine-needle aspiration cytology of a recurrent metastatic JGCT of the anterior abdominal wall, 5 years post-surgery (total abdominal hysterectomy with bilateral salpingo-oophorectomy).

Abdominal Wall Endometriosis at the Cesarean Section Scar

Abdominal wall endometriosis is atypical localization of the extra-pelvic endometriosis with non-specific symptoms and is difficult for diagnosis. Cesarean scar endometriosis (CSE) is the most common type of abdominal wall endometriosis, which usually develops after obstetric operations. We report a case of a 33-year-old woman who had two previous cesarean sections presented with a mass in the subcutaneous tissue of the abdominal wall, approximately 4 cm superior to the Pfannenstiel incision, 5 years after her second lower segment caesarean section. The classic clinical presentation, imaging findings on ultrasonography and computed tomography are analyzed. Treatment with local surgical excision of the mass is discussed. The diagnosis was confirmed with histopathological analysis of the surgical sample. When it comes to the limited painful lesion in the subcutaneous tissue at the cesarean scar, with a pain intensifying during menstruation, the physician should consider cesarean scar endometriosis in women of reproductive age with a history of cesarean section.

[Clinical analysis of 244 cases with abdominal wall endometriosis]

Objective: To investigate the clinical characteristics, diagnosis, treatment, outcomes and prognostic factors of abdominal wall endometriosis (AWE). Methods: A total of 265 AWE patients who underwent surgical treatment in The First Affiliated Hospital of Anhui Medical University from January 2010 to April 2023 were retrospectively selected, and 244 patients had complete follow-up data. According to different depth of lesions, the enrolled patients were divided into three types: type Ⅰ (subcutaneous fat layer, n=30), type Ⅱ (anterior sheath muscle layer, n=174) and type Ⅲ (peritoneum layer, n=40). The general clinical features, perioperative conditions, recurrent outcome and prognostic factors were analyzed in three types. Results: (1) Compared with type Ⅲ patients, the age of onset, parity and incidence of pelvic endometriosis were significantly decreased in type Ⅱ patients [(32.0±4.0) vs (30.0±4.6) years, 1.6±0.6 vs 1.4±0.5, 10.0% (4/40) vs 1.7% (3/174), respectively; all P<0.05], while the proportion of patients with transverse incision was significantly increased [37.5% (15/40) vs 67.3% (115/171); P<0.01]. The first symptoms of type Ⅰ and type Ⅱ were mainly palpable mass in the abdominal wall [73.3% (22/30), 63.2% (110/174), respectively], but the first symptom of type Ⅲ was pain in the abdominal wall [55.0% (22/40); all P<0.05]. (2) No matter the results of preoperative B-ultrasound or intraoperative exploration, the lesion diameters of type Ⅰ, type Ⅱ and type Ⅲ showed significant upward trends (all P<0.05). The proportions of lesion diameter≥3 cm in type Ⅱ and type Ⅲ [67.8% (118/174), 80.0% (32/40)] were significantly higher than that in type Ⅰ (all P<0.05). The median operation time and blood loss of type Ⅰ and Ⅱ were significantly lower than those of type Ⅲ (type Ⅰ vs type Ⅲ: 37.5 vs 50.0 minutes, 10 vs 20 ml, all P<0.05; type Ⅱ vs type Ⅲ: 35.0 vs 50.0 minutes, 10 vs 20 ml, all P<0.05). (3) The median follow-up time was 49 months, the overall symptom remission rate was 98.4% (240/244), and the recurrence rate was 7.0% (17/244). There were no significant differences in recurrence rate and recurrence free time among three types (all P>0.05). Multivariate regression analysis showed that the depth, number, diameter of lesions and postoperative adjuvant medication were not significant factors for postoperative recurrence (all P>0.05). Conclusions: The clinical manifestations of type Ⅲ are the most serious, including obvious abdominal pain symptoms, larger lesion diameter, prolonged operation time, increased intraoperative blood loss and increased incidence of pelvic endometriosis. Complete resection of lesions is an effective treatment for AWE, with high symptom remission rate and low recurrence rate. The depth, number, diameter of lesions and postoperative adjuvant medication are not risk factors for recurrence.

Abdominal scar endometriosis: A case report and review of literature

Endometriosis is defined as the presence of functioning endometrial tissue outside the uterine cavity. Abdominal wall or cutaneous endometriomas are quite uncommon with an incidence of less than 1%. Abdominal wall endometrioma can occur in a previous surgical scar, commonly following obstetrical and gynecological surgeries. Cutaneous endometriosis is difficult to diagnose because of its nonspecific symptoms and is often confused with other dermatological and surgical diseases thereby delaying the diagnosis and management. We are reporting a case of scar endometriosis at the site of previous cesarean scar involving the rectus sheath. The pathogenesis, diagnosis, and treatment of this rare condition are being discussed. Awareness of the clinical features and presentation of this rare condition is essential for timely diagnosis and management.

Favorable Outcome of Repeated Salvage Surgeries for Rare Metastasis to the Ligamentum Teres Hepatis and the Upper Abdominal Wall in a Stage IV Gastric Cancer Patient

Gastric cancer with peritoneal metastases is typically a devastating diagnosis. Ligamentum teres hepatis (LTH) metastasis is an extremely rare presentation with only four known cases. Herein, we report salvage surgery of successive metastases to the abdominal wall and LTH in a patient originally presenting with advanced gastric cancer with peritoneal metastasis, leading to long-term survival. A 72-year-old man with advanced gastric cancer underwent curative-intent distal gastrectomy with D2 lymph node dissection for gastric outlet obstruction. During this procedure, three small peritoneal metastases were detected in the lesser omentum, the small mesentery, and the mesocolon; however, intraoperative abdominal lavage cytology was negative. We added cytoreductive surgery for peritoneal metastasis. The pathological diagnosis of the gastric cancer was tubular adenocarcinoma with pT4aN1pM1(PER/P1b)CY0 stage IV (Japanese classification of gastric carcinoma/JCGC 15th), or T4N1M1b stage IV (UICC 7th). Post-operative adjuvant chemotherapy with S-1 (TS-1)+cisplatin (CDDP) was administered for 8 months followed by S-1 monotherapy for 4 months. At 28 months after the initial surgery, a follow-up computed tomography (CT) detected a small mass beneath the upper abdominal wall. The ass showed mild avidity on 18F-fluorodeoxyglucose positron-emission (FDG-PET) CT. Salvage resection was performed for diagnosis and treatment, and pathological findings were consistent with primary gastric cancer metastasis. At 49 months after the initial gastrectomy, a new lesion was detected in the LTH with a similar level of avidity on FDG-PET CT as the abdominal wall metastatic lesion. We performed a second salvage surgery for the LTH tumor, which also showed pathology of gastric cancer metastasis. There has been no recurrence up to 1 year after the LTH surgery. With multidisciplinary treatment the patient has survived almost 5 years after the initial gastrectomy. Curative-intent gastrectomy with cytoreductive surgery followed by adjuvant chemotherapy for advanced gastric cancer with localized peritoneal metastasis might have had a survival benefit in our patient. Successive salvage surgeries for oligometastatic lesions in the abdominal wall and the LTH also yielded favorable outcomes.

Robot-assisted Laparoscopic Excision of Abdominal Wall Endometrioma Utilizing Intraoperative Ultrasound and Transabdominal Needle Placement

OBJECTIVE

In patients with endometriosis, extra pelvic endometriosis is estimated to have an incidence of 11% and a rare subset of extra pelvic lesions include abdominal wall endometriosis with an incidence of 0.03% to 3.5% [1,2]. Evaluation for and surgical management of abdominal wall endometriosis are an essential skill set for the advanced gynecologic surgeon. In this video, we demonstrate a surgical technique for robot-assisted laparoscopic excision of abdominal wall endometriosis with intraoperative ultrasound-guided needle placement.

DESIGN

Description and demonstration of surgical technique.

SETTING

A patient with previous history of 2 cesarean sections and right lower quadrant cyclic abdominal wall pain; a tertiary care, academic center.

INTERVENTIONS

Intraoperative ultrasound-guided needle placement to map location and boundaries of the lesion followed by minimally invasive resection of the lesion with the intermittent advancement and withdrawal of needles to confirm clear margins.

CONCLUSION

Minimally invasive resection of abdominal wall endometriosis using intraoperative ultrasound-guided needle placement is an effective technique to guide surgical dissection and allow for clear surgical margins and successful treatment of this rare condition.

Endometrioma Within the Anterior Abdominal Wall Causing Cyclic Abdominal Pain

Lesions from endometriosis contain endometrial glands and stroma outside the uterine cavity. The lesions occur in the pelvis but are also found in the bowel, diaphragm, and pleural cavity. Endometriosis within the extraperitoneal abdominal wall is rare, though, and usually within c-section scars (incidence is .03%-.5%). The typical triad includes: mass in the abdominal wall, cyclical pain, and history of previous abdominal surgery. We present the case of a 28-year-old female with a past history of cesarean section and obesity (BMI = 31) who presented with approximately 3 years of abdominal pain which was "waxing and waning" in severity depending on her menstrual cycle. Multiple doctors and US imaging did not reveal a diagnosis. During consultation, she had a palpable 3 cm mass several centimeters above and right of her abdominal incision. She underwent a CT showing an inflamed subcutaneous mass abutting her anterior rectus sheath. She underwent wide excision which confirmed the diagnosis of endometrioma. This case demonstrates the need for good history and physical exam skills, as well as proficiency in reviewing radiographic imaging. Due to habitus and pain, the physical exam was difficult. However, there was a firm mass upon deep palpation. Her initial imaging was "negative," but review of the images revealed only intraperitoneal views and further imaging revealed the mass. There must be high clinical suspicion for this disease because failure to remove all tissue (including the surrounding fibrosis and desmoplastic tissue) or biopsy can lead to spread of residual endometrial cells and recurrence.

[Abdominal wall skin nodules revealing xanthogranulomatous pylonephritis]

INTRODUCTION

Xanthogranulomatous pyelonephritis is a chronic pyelonephritis characterized by an inflammatory granulomatous reaction that destroys the renal parenchyma. It is an uncommon entity. Diffuse inflammation has the potential to spread to nearby organs, especially the skin.

OBSERVATION

A 73-year-old patient presented with a three-year history of painful and fistulized nodules on the abdominal wall. The results of abdominal computed tomography and magnetic resonance imaging revealed xanthogranulomatous pyelonephritis with extension to the skin, colon, and psoas muscle. The skin lesions were improved by a double antibiotic therapy. The patient was advised to have a radical left nephrectomy, but he refused surgery and was then lost to follow-up.

CONCLUSION

We report an uncommon case of xanthogranulomatous pyelonephritis revealed by cutaneous nodules of the abdominal wall, with an extension toward the skin, the colon and the psoas muscle.

Subcutaneous Leiomyosarcoma Of Supra-Pubic Region Managed With Wide Local Excision And Total Penectomy

Subcutaneous leiomyosarcomas (LMS) are rare soft tissue sarcomas arising from small-to-medium-sized blood vessels. Involvement of the anterior abdominal wall is extremely rare. We present a case of a 72-year-old gentleman who presented with 3 months history of a progressively increasing mass in the supra-pubic region reaching the root of the penis without any regional lymphadenopathy. Magnetic resonance imaging (MRI) pelvis showed a large heterogeneous mass in the lower abdomen indenting the penile corpora. Complete pathological clearance was achieved by wide excision of the mass with total penectomy and cutaneous urethrostomy. The patient received adjuvant radiation therapy and is free of local recurrence or distant metastasis two years after the surgery.

Multifunctional Microgel-Based Cream Hydrogels for Postoperative Abdominal Adhesion Prevention

Postoperative abdominal adhesions are a common problem after surgery and can produce serious complications. Current antiadhesive strategies focus mostly on physical barriers and are unsatisfactory and inefficient. In this study, we designed and synthesized advanced injectable cream-like hydrogels with multiple functionalities, including rapid gelation, self-healing, antioxidation, anti-inflammation, and anti-cell adhesion. The multifunctional hydrogels were facilely formed by the conjugation reaction of epigallocatechin-3-gallate (EGCG) and hyaluronic acid (HA)-based microgels and poly(vinyl alcohol) (PVA) based on the dynamic boronic ester bond. The physicochemical properties of the hydrogels including antioxidative and anti-inflammatory activities were systematically characterized. A mouse cecum-abdominal wall adhesion model was implemented to investigate the efficacy of our microgel-based hydrogels in preventing postoperative abdominal adhesions. The hydrogels, with a high molecular weight HA, significantly decreased the inflammation, oxidative stress, and fibrosis and reduced the abdominal adhesion formation, compared to the commercial Seprafilm group or Injury-only group. Label-free quantitative proteomics analysis demonstrated that S100A8 and S100A9 expressions were associated with adhesion formation; the microgel-containing hydrogels inhibited these expressions. The microgel-containing hydrogels with multifunctionality decreased the formation of postoperative intra-abdominal adhesions in a murine model, demonstrating promise for clinical applications.

The clinical features and long-term surgical outcomes of different types of abdominal wall endometriosis

PURPOSE

To classify abdominal wall endometriosis (AWE) according to the invasive levels of tissue mass, and to compare the differences in clinical characteristics between different types of AWE.

METHODS

In this study, we retrospectively analyzed the clinical data of 367 patients who had undergone resection of abdominal-wall endometriotic lesions at the Peking Union Medical College Hospital from January 2008 to December 2018, and we divided the patients into three types according to their deepest level of lesion invasion. Type I designated invasion of skin and subcutaneous tissue; type II, of fascia and rectus abdominis; and type III, of peritoneum. We classified, compared, and analyzed the general conditions, clinical manifestations, auxiliary examinations, surgical conditions, postoperative conditions, and recurrence status of patients.

RESULTS

Of the 367 patients, type I patients accounted for 13.62%, type II patients for 56.68%, and type III for 29.7%. With respect to group comparisons, we observed that as the location of the mass deepened, the rate of concurrent pelvic endometriosis increased (P = 0.007), recurrent AWE was augmented (P = 0.02), the size of the mass increased (P < 0.001), the rate of multiple lesions became elevated (P < 0.001), the rate of mesh implantation increased (P < 0.001), the length of postoperative hospital stay (P < 0.001) was lengthened, the number of postoperative fever cases (P = 0.006) increased, and the risk of drainage placement (P < 0.001) was enhanced. The 5-year cumulative recurrence rate was 3.3%, and there was no significant difference in the recurrence rate among various types of AWE.

CONCLUSION

Type III AWE carries more severe clinical manifestations, larger lesion size, longer operative time, greater intraoperative surgical difficulty, higher necessity of mesh implantation, and longer postoperative recovery process. Complete resection of AWE lesion is the main therapeutically approach and shows relatively low long-term recurrency rate.

Preventive effect of fucoxanthin administration on intra-abdominal adhesion: An experimental animal study

BACKGROUND

The most common cause of intra-abdominal adhesion (IAA) is previous abdominal surgery and mortality. IAA can cause serious complications such as chronic abdominal pain, ileus, and infertility. Approximately 3% of all laparotomies are related to adhesions. IAA reduces the quality of life of the patient, causes morbidity, and increases health expenditures. In this study, we aimed to investigate the preventive effect of fucoxanthin (Fx) on IAA in the intra-abdominal surgical adhesion model that experimentally created in rats.

METHODS

This study used 21 Sprague-Dawley rats divided into three groups. After anesthesia, the abdomen was opened, the cecum and right abdominal wall were damaged with a sterile toothbrush until petechiae bleeding was seen. No additional action was taken to the control group. In the sham group, 5 cc saline solution was released into the peritoneum before the abdomen was closed. In the Fx group, 35 mg/kg Fx was instilled intraperitoneally and the abdomen was closed. On the 21st post-operative day, all subjects were anesthetized with standard anesthesia. Macroscopic adhesions were quantitatively evaluated according to the Mazuji classifica-tion. The cecum anterior wall and parietal peritoneum were excised for pathological sampling. A pathologist, unaware of the groups, evaluated inflammation, fibroblastic activity, and vascular proliferation. In addition, serum tumor necrosis factor-alpha (TNF-α) and interleukin-10 levels were measured.

RESULTS

No rat was lost during the study period. Congenital adhesion was not observed in any of the subjects at the first laparo-tomy. Adhesion was significantly less macroscopically in the Fx group compared to the control and sham group (p<0.001 and p<0.001). Fibroblastic activity was found to be significantly less in the Fx group compared to the sham and control groups (p<0.001 and p<0.001). Vascular proliferation was found to be significantly less in the Fx group than in the sham and control groups (p<0.001 and p<0.001). The inflammation score was significantly lower in the Fx group compared to the other two groups (p<0.001 and p<0.001). The inflam-mation score in the sham group was lower than the control group and was statistically significant (p<0.001). TNF-α level was found to be statistically significantly lower in the Fx group compared to the sham and control groups (p<0.001 and p<0.001).

CONCLUSION

As a result of experimental study, we can say that Fx is effective in preventing IAAs and decreases the level of TNF-α, a pro-inflammatory cytokine.

Abdominal wall reconstruction using Omental Flap with Mesh repair following resection of Aggressive Abdominal Wall Neoplasms

BACKGROUND

Resection of large anterior abdominal wall tumors causes a large full-thickness abdominal wall defects, and the repair of these defects remains a challenging point.

METHODS

Between July 2016 and February 2021, we retrospectively reviewed the internal database registry of the Oncology Center, Mansoura University (OCMU) Egypt, for patients with large abdominal wall defects after abdominal wall tumors resection and repair with omental flaps and synthetic Polypropylene (PP) mesh. Thirty-two patients met the inclusion criteria. They were analyzed for demographics, operative data including defect size, mesh size, intrabdominal tumor extension and postoperative outcomes and complications.

RESULTS

Thirty-Two patients with abdominal wall neoplasm underwent local resection in our center and the defect was closed with omental flap and PP mesh. The mean operative time was 143.75 ± 30.77 mins. The mean size of the abdominal wall defect was 50.78 cm2 (range: 25 - 90 cm2). The meshes used in reconstruction had a mean size of 89.53 cm2 (range: 55 - 130 cm2). The median follow-up period of the patients was 13.5 months (range: 5-54 months). Post-operative complications included infection (n = 4 cases), seroma (n = 2 cases), hematoma (n =1 case) and abnormal sensation (n = 5 cases). Tumor recurrence was reported in two cases and no cases developed incisional hernia during the follow up period.

CONCLUSION

Immediate use of omental flap with synthetic (PP) mesh for reconstruction of abdominal wall defects is a feasible technique and has avoided the complications associated with the use of synthetic mesh alone.

Ectopic extramammary Paget's disease of the abdominal wall with abdominoplasty reconstruction

Ectopic extramammary Paget's disease describes an exceedingly rare intraepithelial adenocarcinoma arising within non-apocrine tissues. We present a case report of E-EPMD arising on the lower abdomen without underlying secondary malignancy in a 56-year-old female patient. We performed a wide local excision of the lesion with subsequent mini abdominoplasty reconstruction.

[Recurrent Darier-Ferrand dermatofibrosarcoma in the abdominal wall: the role of preoperative radiotherapy (case report)]

Dermatofibrosarcoma is a rare cancer, accounting for 0.01% of all cancers. We here report the case of a 44-year-old female patient presenting with the 5th recurrence of locally advanced Darier-Ferrand dermatofibrosarcoma, that progressed on many cycles of neoadjuvant therapy and required emergency radiotherapy with good response. This allowed to perform wide excision of the tumor with healthy limits. The patient had remission after 1 year of follow-up. Prognosis for patients with Darier-Ferrand dermatofibrosarcoma is generally excellent. Wide surgery and the advent of Mohs surgery have improved local control. The role of radiotherapy is limited for non-resectable tumors or positive margins.

Abdominal wall endometriosis: a case report

Abdominal wall endometriosis is the development of endometrial tissue in the anterior abdomen usually due to an operation in which the uterus is manipulated. We herein delineate the presentation, clinical investigation, and surgical treatment of an abdominal wall endometriosis case. A 42-year-old female presented with acute abdominal pain in the lower quadrants in the margins of an old cesarean scar. Two masses in the abdominal wall highly suspected of consisting of endometrial tissue were found during the investigation of the patient. These ones were removed in surgery and endometrial tissue secondary to previous cesarean section was confirmed after histological analysis. Consequently, although rare, if a painful mass in a surgical scar, such as a Pfannenstiel incision, is found in women of reproductive age with a history of obstetric surgery, the differential diagnosis shall include endometriosis. There is a portion of cases in which endometriosis recurs within five years following conservative surgery.

Endométriose de la paroi abdominale: à propos de deux cas

L'endométriose de la paroi abdominale est une maladie rare qui se développe généralement sur une cicatrice de césarienne. Bien que fréquemment observée dans le tissu adipeux cutané et sous-cutané en regard de la cicatrice de césarienne, sa localisation intramusculaire est possible mais reste rare. Le traitement repose sur l'exérèse chirurgicale de la lésion associée ou non à une thérapie hormonale. L´exérèse chirurgicale large reste le traitement de choix de la maladie mais expose au risque de hernie de la paroi abdominale. Nous rapportons deux cas d'endométriose pariétale survenant après cicatrice de Pfannstiel pour césarienne colligés au service de chirurgie de l'Hôpital régional de Zaghouan.

Prevention of Postsurgical Abdominal Adhesion Using Electrospun TPU Nanofibers in Rat Model

Intra-abdominal adhesions following surgery are a challenging problem in surgical practice. This study fabricated different thermoplastic polyurethane (TPU) nanofibers with different average diameters using the electrospinning method. The conditions were evaluated by scanning electron microscopy (SEM), atomic force microscope (AFM), and Fourier transform infrared spectrometer (FTIR) analysis. A static tensile test was applied using a strength testing device to assess the mechanical properties of the electrospun scaffolds. By changing the effective electrospinning parameters, the best quality of nanofibers could be achieved with the lowest bead numbers. The electrospun nanofibers were evaluated in vivo using a rat cecal abrasion model. The macroscopic evaluation and the microscopic study, including the degree of adhesion and inflammation, were investigated after three and five weeks. The resultant electrospun TPU nanofibers had diameters ranging from about 200 to 1000 nm. The diameters and morphology of the nanofibers were significantly affected by the concentration of polymer. Uniform TPU nanofibers without beads could be prepared by electrospinning through reasonable control of the process concentration. These nanofibers' biodegradability and antibacterial properties were investigated by weight loss measurement and microdilution methods, respectively. The purpose of this study was to provide electrospun nanofibers having biodegradability and antibacterial properties that prevent any adhesions or inflammation after pelvic and abdominal surgeries. The in vivo experiments revealed that electrospun TPU nanofibers reduced the degree of abdominal adhesions. The histopathological study confirmed only a small extent of inflammatory cell infiltration in the 8% and 10% TPU. Conclusively, nanofibers containing 8% TPU significantly decreased the incidence and severity of postsurgical adhesions, and it is expected to be used in clinical applications in the future.

Cutaneous Endometriosis: A Case Report and Review of the Literature

BACKGROUND Endometriosis is a unique entity described in ample literature as the decidualization of endometrial tissues under the influence of gynecological hormones outside the uterine cavity. The post-surgical presence of ectopic endometrial tissue on the skin is known as abdominal wall endometriosis, cutaneous endometriosis, or scar endometriosis. Iatrogenic implantation of detached endometrial tissues at the incision site is the most widely accepted theory for this rare monad. The unspecific scar endometriosis presentation makes it challenging to diagnose. Moreover, it can easily be confused with hematoma, hernia, lipoma, abscess, scar granuloma, and tumor. Here, we report and discuss a rare case of scar endometriosis with various available treatment modalities. CASE REPORT We delineate a case of a 39-year-old woman with abdominal wall cutaneous endometriosis. An "inverted T" incision opened the abdominal and uterine cavity as it was a problematic preterm breech in labor. After an uneventful postoperative and postpartum period, she presented with a painful, discolored nodular mass of approximately 3 cm in diameter at the left border of the cesarian scar, developed over 1.5 years, often accompanied by drainage of brownish discharge. Ultrasonography with color Doppler showed a hypoechoic lesion with internal vascularity, corroborated our preliminary diagnosis of scar endometriosis, which was further confirmed by surgical excision and histopathology. CONCLUSIONS A proper surgical resection is the standard treatment line for scar endometriosis. However, patients need regular follow-up to look for recurrences, even after treatment. Further studies are recommended to establish factors associated with cutaneous endometriosis recurrence.

Synchronous Fibromatosis Indistinguishable from Suspected Synchronous Gastrointestinal Stromal Tumor: A Case Report

Desmoid tumors most commonly occur in the anterior abdominal wall in approximately 50% of cases and are locally aggressive. We describe a case of a 38-year-old lady who was investigated as a case of gastrointestinal tumor. Post-operative immunohistochemistry staining showed the presence of a synchronous desmoid in the abdominal wall and proximal ileum. Wide local excision remains the gold-standard of treatment with pharmacotherapeutics and radiotherapy serving as adjuvant or palliative treatment options.

Clear-cell carcinoma originating from cesarean section scar: two case reports

BACKGROUND

Clear-cell carcinoma arising from the surgical cesarean section scar is very infrequent. The present study reports two patients with clear-cell carcinoma arising from an abdominal wall scar 20 and 23 years after their last cesarean section.

CASE PRESENTATION

Both Iranian patients had prior cesarean sections nearly 20 years earlier. Patients 1 and 2 had transverse and vertical abdominal incisions, respectively. The initial clinical presentation was a huge lower abdominal mass at the site of the previous cesarean section scar. Both patients underwent abdominal wall mass biopsy. The histological analysis revealed the presence of malignancy. Both patients underwent full-thickness resection of the abdominal wall mass. All surgical margins were tumor-free; however, patient 1 had a very narrow tumor-free margin near the pubic symphysis. As the imaging report of patient 2 revealed the presence of a pelvic mass, the exploration of the intraperitoneal space, simple total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), and the excision of enlarged pelvic lymph nodes were performed during the surgery. Six cycles of paclitaxel and carboplatin every 3 weeks as adjuvant chemotherapy was administered for both patients after the surgery. One of the patients had disease recurrence 5 months after the termination of chemotherapy, and the other is still disease-free. These two patients had similar pathology and received a similar initial adjuvant treatment; however, they were different in terms of the direction of tumor spread, tumor distance from the pubic symphysis, status of tumor margins, and surgical procedures.

CONCLUSIONS

We encountered distinct prognoses in the clear-cell carcinoma of cesarean section scars presented herein. The researchers can recommend complete surgical excision of the abdominal wall mass with wide tumor-free margins, exploration of the abdominopelvic space, TAH, and BSO during the first surgery.

Giant pseudocyst of the abdominal wall following incisional ventral hernia repair: an extremely rare clinical entity. Report of a case

BACKGROUND

The gold standard treatment for incisional ventral hernia (IVH) is a surgical repair with mesh employment, nevertheless this procedure is burdened by several post-operative complications; among these latter, giant pseudocyst of abdominal wall (GPAW) formation is one of the most rare and its etiopathogenesis remains unclear.

CASE REPORT

We describe the case report of a 36 years old, diabetic and obese woman, previously underwent to a csection and IVH repair with on-lay mesh placement, presented to our unit with an asymptomatic left iliac fossa swelling. At ultrasound (US) and CT scan examination it appears to be a subcutaneous cyst of the anterior abdominal wall associated with a recurrent IVH. Therefore, she underwent to a surgical procedure in order to accomplish a complete excision of the lesion along with a repair of the incisional IVH, with a sub-lay mesh positioning. The extensive dead space resulting from the procedure was managed with a quilting suture. No recurrence or complications have been detected at 2 years follow up.

CONCLUSION

GPAWs are a rare clinical entity following IVH repair, which occur commonly in female obese patients treated with on-lay mesh positioning. The only effective and definitive treatment is a complete surgical excision along with a correct management of the dead space resulting from the surgical procedure, in order to reduce the recurrence rate.

KEY WORDS

Abdominal wall, Incisional hernia, Mesh, Pseudocyst, Surgery.

Synchronous diagnosis of anaplastic large cell lymphoma and multiple myeloma in a patient: A case report

RATIONALE

Synchronous development of both anaplastic large cell lymphoma (ALCL) and multiple myeloma (MM) in a patient is rare. To our knowledge, until now only one case has been reported. Treatment needs to cover both and is a challenge. Here we reported another case and discussed the diagnosis and treatment.

PATIENT CONCERNS

This is a 63-year old woman who presented with a mass in upper abdominal skin. Positron emission tomography/computed tomography (PET/CT) showed the high metabolism in left abdominal skin and left axillary lymph nodes. Histopathologic and immunohistochemical evaluation identified the cutaneous mass as an ALK-negative ALCL. Bone marrow smear showed increased plasma cells which expressed CD38, CD138, and cLambda concomitantly. The increased monoclonal immunoglobulin IgD λ was detected by immunofixation electrophoresis.

DIAGNOSES

Diagnosis of both ALCL and MM was confirmed.

INTERVENTIONS

The patient successively received 6 cycles of B-CHOD regimen, one cycle of ID regimen, 2 cycles of DHAX regimen, one cycle of L-DA-EPOCH and autologous stem cell transplantation (ASCT). Then lenalidomide was performed as a maintenance therapy.

OUTCOMES

Both ALCL and MM achieved complete remission.

LESSONS

We reported a very rare case with synchronous development of ALCL and MM, in whom a good therapeutic response to chemotherapies followed by ASCT has been observed.

Abdominal skin inflammation as an initial symptom of a perforating gastric foreign body: A case report

RATIONALE

Foreign bodies are frequently ingested, but only approximately 1% of them cause perforation. Perforations in the lesser curvature of the stomach are exceedingly rare. Here, we report a case of gastric perforation in the lesser curvature caused by a foreign body. The patient presented to the clinic complaining of abdominal skin swelling and reddening with upper abdominal discomfort as the initial symptoms.

PATIENT CONCERNS

An 83-year-old female presented with a mass in the middle of the epigastrium for 10 days. Physical examination found an apparent local tenderness and inflammatory mass in the upper abdominal wall. Her body temperature was normal (37.5°C) and the white blood cell count was elevated (8.12 × 10/L [reference value 3.5-9.5 × 10/L]).

DIAGNOSES

The ultrasound examination of the abdomen revealed a 4 cm strip-like hyperechoic object entangled in the muscles of the abdominal wall. The computed tomography scan revealed a thin strip of bone-like hyperdense shadow. Intraoperative findings showed a sharp fishbone protruding from the lesser curvature of the stomach into the abdominal cavity, part of which remained in the gastric cavity. The postoperative pathological report revealed chronic suppurative inflammation with abscess and sinus canal formation.

INTERVENTIONS & OUTCOMES

The patient underwent a gastric foreign body removal with partial gastrectomy. Anti-inflammatory treatment post-surgery rapidly relieved the patient's symptoms of discomfort in the upper abdomen. At the 1-month follow-up, the patient showed no discomfort in the upper abdomen and the inflammatory mass was no longer present.

LESSONS

A foreign body had penetrated through the lesser curvature of the stomach, an area with a flat gastric wall, which occurs infrequently. In such cases, computed tomography is the gold standard for diagnosis of foreign bodies in the digestive tract. Ultrasound can also be used as a supplemental diagnostic technique. It is recommended that people who wear dentures should exercise caution while eating, especially when the food contains bones.

Bilateral thoracic disc herniation with abdominal wall paresis: a case report

We present a rare case of a patient initially presenting with unilateral abdominal wall bulging and radicular pain caused by a lateral disc herniation at Th11/12, later suffering from a hernia recurrence with bilateral disc prolapse and motor deficits. The patient underwent sequesterectomy via a right hemilaminectomy at Th11, and after 8 weeks, a bilateral sequesterectomy with semirigid fusion Th11/12 was performed. Unilateral motor deficits at the thoracic level have been discussed in case reports; a bilateral disc protrusion with abdominal wall bulging occurring as a recurrent disc herniation has never been described before.

Novel Creation of a Noneverted Stoma During Ileal Conduit Urinary Diversion: Technique and Short-term Outcomes

OBJECTIVE

To report our experience with a noneverted stoma technique used in ileal conduit urinary diversion. We successfully utilize this technique in patients when traditional everted stoma maturation is difficult due to a thick abdominal wall, bulky mesentery, and poor bowel compliance.

METHODS

We retrospectively reviewed all patients who underwent surgical creation of ileal conduit using a noneverted stoma technique between 2009 and 2018. We recorded demographic and perioperative information, including 30-day postoperative complications, and stoma appearance at last follow-up visit. Using R software, chi-square testing of the distribution of stoma outcomes for obese and nonobese patients was performed.

RESULTS

There were a total of 42 patients who underwent noneverted stoma maturation technique by a single surgeon. Our cohort meets obese criteria with a mean body mass index (BMI) of 30.2. Mean length of follow-up was 16.6 months (1-62). On follow-up, 35 (83.3%) of stomas were pink and everted appearing, 4 (9.5%) were flush, small, or noneverted, 1 (2.3%) had an eschar or area of granulation tissue around the stoma, and 2 (4.7%) did not have a stoma description documented. There were 9 (21%) stoma-related complications in our cohort. There was no statistical difference in stoma outcomes between obese (BMI > 30) and nonobese (BMI < 30) patients (P= .65).

CONCLUSION

Ileal conduit creation with a noneverted stoma provides good stoma protuberance in patients with a thick abdominal wall, bulky mesentery, and poor bowel compliance. This technique is safe and should be considered in patients in whom stoma maturation is difficult.

H-Bonding Supramolecular Hydrogels with Promising Mechanical Strength and Shape Memory Properties for Postoperative Antiadhesion Application

Development of a physical barrier with mechanical properties similar to human smooth muscle and an on-demand degradation profile is crucial for the clinical prevention of postoperative adhesion. Herein, a series of supramolecular hydrogels (PMI hydrogels) composed of poly(ethylene glycol) (PEG), methylenediphenyl 4, 4-diisocyanate (MDI), and imidazolidinyl urea (IU, hydrogen bonding reinforced factor) with biodegradability and high toughness are reported to serve as physical barriers for abdominal adhesion prevention. The tensile fracture strength and strain of the PMI hydrogels could be adjusted in the ranges of 0.6-2.3 MPa and 100-440%, respectively, and their Young's moduli (0.2-1.6 MPa) are close to that of human soft tissues like smooth muscle and skin tissue as well as they have outstanding shape memory properties. The PMI hydrogels show good cell and tissue biocompatibility, and the in vivo retention time is in accord with the needs for the postoperative antiadhesion physical barriers. Through an abdominal defect model on mice, this study shows that the PMI hydrogel can completely prevent tissue adhesion compared to the commercialized Seprafilm with high safety. Owing to the promising mechanical properties and good biocompatibility, the PMI hydrogels may be extended for various biomedical applications and the development of advanced flexible electronic devices.

Use of Shear Wave Elastography to Quantify Abdominal Wall Muscular Properties in Patients With Incisional Hernia

Shear wave elastography (SWE) is a potential modality that quantitatively measures the elasticity (shear wave speed [SWS]) of musculoskeletal structure. This SWS was bilaterally measured in the rectus abdominis (RA), external oblique (EO) muscle, internal oblique (IO) muscle and transversus abdominis (TrA) using SWE in 28 patients with incisional hernia and 14 healthy controls. The differences in muscle thickness for IO and TrA were significant between the two groups (p < 0.05). The SWS of RA, EO, IO and TrA was significantly higher in the incisional hernia patient group than in the healthy controls (p < 0.05). Significant differences were also observed between the upper and lower points in both groups (p < 0.05). The measurements of SWS help in evaluating the elastic properties of abdominal wall muscles, which could further aid in preparing treatment plans to improve muscle strength.

Sister Mary Joseph's nodule: the tip of an iceberg

Sister Mary Joseph's nodule is a rare palpable umbilical cutaneous lesion as a result of an advanced intra-abdominal and/or pelvic malignancy. It may be the initial clinical manifestation of an underlying malignancy, originating mainly from the gastro-digestive or genito-urinary tract. We present here a rare case of a 67-year-old woman with a Sister Mary Joseph's nodule. On surgical exploration, a left ovarian mass with anterior abdominal wall metastasis, ascites and extensive intra-abdominal metastatic lesions were observed. Our case report shows the importance of a careful physical examination as an invaluable diagnostic tool in modern medicine. High index of suspicion and awareness of this clinical sign may lead to the detection of the primary source, to its diagnosis and more appropriate treatment options in order to achieve the best survival possibility. KEY WORDS: Ovarian cancer, Sister Mary Joseph's nodule, Umbilical metastasis.

Multivisceral resection of locally advanced colorectal cancer in an African referral centre

BACKGROUND

Colorectal cancer (CRC) is common and often presents with advanced disease in Africa. Multivisceral resection (MVR) improves survival in locally advanced (T4b) CRC. The aim was to describe the management and outcomes of patients with clinical T4b CRC without metastatic disease who underwent MVR.

METHODS

A retrospective review of patients with T4 CRC who underwent MVR between January 2008 and December 2013.

RESULTS

Four hundred and ninety-four patients were included. Of the 158 with suspected T4 cancer, 44 had MVR, of which one was excluded due to metastases. The mean age was 64 years. The male to female ratio was 1:1. The most commonly resected extra-colorectal structure was the abdominal wall (21%). The median survival was 68 months (SD 13.9). The 5-year disease free (DFS) and overall survival (OS) were 46% and 55%, respectively. Survival of patients with colon and rectum cancer was similar. Intraoperative tumour spillage, vascular/perineural invasion, and anastomotic leakage were independent predictors of survival.

CONCLUSION

Multivisceral resection of locally advanced (T4b) CRC is feasible in the African context. Complete resection improves survival and should be the goal.

Fetal umbilical cord cyst may evolve to omphalocele during pregnancy

Omphalocele is rarely complicated by umbilical cord cysts. In our case, an umbilical cord cyst and fetal ascites were detected at 26 weeks' gestation in a fetus with trisomy 13. This changed to omphalocele with subsequently absorbed fetal ascites at 35 weeks' gestation. We propose two hypotheses. The abdominal wall may have been physically pierced or an omphalocele might have preexisted, and the intestinal tract in the hernia sac was pushed by fetal ascites.

Assessment of the diagnostic efficacy of abdominal ultrasonography and cine magnetic resonance imaging in detecting abdominal adhesions: A double-blind research study

PURPOSE

This cohort aimed to determine the efficacy and safety of abdominal ulrasonography and cine-MRI by a double-blind study in the diagnosis of intraabdominal organs and abdominal wall adhesions in patients with previous abdominal operations.

METHODS

Between 2017 and 2019, 108 consecutive patients were prospectively included in the study. Visceral slide and induced visceral slide were measured during AU and cine-MRI. An abdominal map consisting of nine segments was created to document the location and extent of the adhesion. The degree and severity of the adhesions detected by the radiologist preoperatively and detected in surgery as the gold standard was recorded in the same abdominal zones. AU, c-MRI and intraoperative findings were correlated.

RESULTS

The mean age was 53.0 ± 10.3 years, body mass index was 30.4 ± 3.4, male (52.8 %) and female (47.2 %). According to the total nine zones, the sensitivity of AU was 91.4 %, specificity was 100 %, positive predictive value was 90.7 %, negative predictive value was 100 % and diagnostic accuracy was 87.9 %. Considering the total zones, the sensitivity of c-MRI was 90.8 %, specificity was 100 %, PPV was 90.7 %, NPV was 100 % and diagnostic accuracy was 91.7 %. A comparison of AU and c-MRI showed no significant difference in the detection of adhesions to the abdominal wall; however, c-MRI was superior in detecting intraabdominal organs adhesion.

CONCLUSION

We have demonstrated that AU and c-MRI are accurate for diagnosing adhesions in patients undergoing repeated surgery and may have a place on planning elective laparoscopic or open surgery to avoid bowel injury.

[A focal abdominal swelling after an accident with a 'space scooter']

A 7-year-old boy presents at the Emergency Department with an abdominal swelling after an accident with a space scooter. He was diagnosed with a traumatic anterior abdominal wall hernia, for which he underwent surgical correction.