Pelvic Abscess Research Articles

Successful endovascular stenting of a bleeding external iliac vein mycotic aneurysm in an oncologic patient: a case report

BackgroundMycotic aneurysms are rare vascular lesions, occurring in 0.6–2% of arterial aneurysms but with no reported venous cases. Venous aneurysms unrelated to an underlying infectious process have been previously described and are typically surgically repaired due to risk of thromboembolic events.Case presentationThis case reports a bleeding external iliac vein mycotic aneurysm secondary to erosion of a chronic pelvic abscess, successfully treated with endovascular stenting, in an oncologic patient without alternative therapeutic options.ConclusionVenous aneurysms are uncommon vascular lesions which have historically been treated with open surgical repair. Given the lower degree of procedural morbidity, endovascular management of these lesions may be an effective option in the appropriate setting, particularly as a last resort in patients without surgical treatment options.

E-health and interventional radiology in gynecology

PurposeThis paper aims to summarize the radiological interventions that can be used by obstetricians and gynecologists.Design/methodology/approachE-health systems apply in all hospital sectors in the world; interventional radiology (IR) now includes transcatheter and percutaneous techniques that can be applied to various organ systems, including the female reproductive system and pelvis. Interventional radiologists can now offer many services to obstetricians and gynecologists. With the advent of new procedures and refinement of existing techniques, there are now a number of procedures that can be used to treat both vascular and non-vascular diseases. This review summarizes the radiological interventions that can be used by obstetricians and gynecologists.FindingsThis review is intended to help gynecologists and obstetricians understand the role of IR in their specialty. Many valuable vascular and nonvascular interventional services can be provided by radiologists for both obstetric and gynecological indications. Many of these IR procedures are minimally invasive with less risk to the patients.Originality/valueIR is now being used to treat some conditions encountered in obstetrics and gynecology, in particular, uterine leiomyomas, placenta accreta, postpartum hemorrhage and pelvic congestion syndrome. Moreover, with the help of IR, radiologists can also manage several nonvascular pathologies, including drainage of pelvic abscesses, fallopian tube recanalization, image-guided biopsy and fluid collections involving ovarian lesions. The major challenges faced when performing obstetric IR procedures are reduction of radiation exposure for the patient and fetus and preservation of fertility. This review highlights the role of IR in the treatment of various vascular and nonvascular pathologies encountered in obstetrics and gynecology.

Acute appendicitis in elderly during Covid-19 pandemic.

PurposeDuring the past months, the Italian Government has reduced the restrictions and access to hospitals. Since then, up to 40% of non-traumatic abdominal emergencies have had unusual delayed treatment. Given the rapidly evolving situation and the absence of evidence to support recommendations during the pandemic, it is useful to assess how the current situation is influencing the management of elderly with acute appendicitis.MethodsBetween February 2020 and December 2020, all patients older than 68 years old undergone appendectomy were included. Surgical approach, hospital stay, post-operative complications, radiology reports, and histologic examination were included in the retrospective analysis and compared with a same sample of the same period before the pandemic.ResultsTwenty-seven patients underwent appendectomy for acute appendicitis during the pandemic and 34 patients in the pre-outbreak period. Laparoscopic approach was completed in 51.8% of the cases, while conversion to laparotomy in 22.3% of patients and open procedure in the 25.9%, before the pandemic 73.6%, 14.7%, and 11.7%, respectively. During the pandemic, complicated appendicitis occurred in 59.3% of the cases (26.5% before the outbreak). One patient was treated for a pelvic abscess, while no minor complications were detected. No mortality rate was reported, with a mean hospital stay of 5.64 days during the outbreak and 4.21 days before the pandemic.ConclusionOur data highlighted a partial delay in diagnosis in the elderly group, and an increase in complicated appendicitis also demonstrated by the need for conversion to laparotomy.

Delayed coloanal anastomosis as a stoma-sparing alternative to immediate coloanal anastomosis: A systematic review and meta-analysis.

Recent clinical trials have demonstrated favorable outcomes associated with trans-anal colonic pull-through for rectal resection followed by delayed coloanal anastomoses (DCA), resulting in a resurgence in popularity of the technique. This meta-analysis aims to review existing literature to evaluate the postoperative complications associated with DCA, and to make comparisons with immediate coloanal anastomoses (ICA) after colorectal resection to assess the suitability of DCA as an alternative form of surgical treatment. Medline and Embase databases were reviewed from inception until 31 July 2020 in accordance with PRISMA guidelines. Single-arm studies that involved patients undergoing DCA for benign or malignant causes were selected, and meta-analysis of proportions was conducted to determine the prevalence of postoperative complications following DCA. Comparative studies comparing postoperative outcomes between DCA and ICA were also included for comparative meta-analysis. Patients undergoing DCA were significantly less likely to require diverting stoma construction as compared to ICA (odds ratio [OR]=0.04; confidence interval [CI]: 0.02-0.07; P < 0.001). Overall postoperative morbidity (OR=0.50; 95% CI: 0.23-1.12; P=0.09) and mortality (OR=0.49, 95% CI: 0.12-1.98; P=0.32) was comparable between DCA and ICA groups. No significant differences in perioperative complications, such as anastomotic leakage (OR=0.42; 95% CI: 0.11-1.64; P=0.21), postoperative ileus, pelvic abscesses, or sepsis, were noted between DCA and ICA. Our study shows no differences in complications or functional outcomes between DCA and ICA. Pooled analysis expectedly revealed a lower rate of diverting stoma in patients undergoing DCA. DCA is thus a safe alternative to current surgical practices where avoidance of a stoma is desired.

Outcomes associated with the use of a new powered circular stapler for left-sided colorectal reconstructions: a propensity score matching-adjusted indirect comparison with manual circular staplers

BackgroundThis was a retrospective, matching-adjusted indirect comparison of clinical outcomes between patients from a single-arm trial of the ECHELON CIRCULAR™ Powered Stapler (ECP) and those from a historical cohort of patients who underwent left-sided colorectal resection using conventional manual circular staplers, extracted from the Premier Healthcare Database.MethodsPatients in the ECP trial cohort were propensity score matched to those in the historical cohort through nearest neighbor matching. Outcomes included 30-day readmission rates; length of stay (LOS) for the index admission; rates of anastomotic leak, pelvic abscess, ileus/small bowel obstruction, infection, bleeding, and stoma creation.ResultsThe study included 168 patients in the ECP trial cohort and 4544 patients in the historical cohort; 165 ECP trial patients were matched to 1348 historical cohort patients. After matching, conversions were more prevalent in the historical cohort than the ECP trial cohort (4.2% ECP vs. 10.2% historical, p = 0.001). Relative to the historical cohort, the ECP trial cohort had statistically significant lower rates of 30-day inpatient readmission (6.1% vs. 10.8%, p = 0.019), anastomotic leak (1.8% vs. 6.9%, p < 0.001), ileus/small bowel obstruction (4.8% vs. 14.7%, p < 0.001), infection (1.8% vs. 5.7%, p = 0.001), and bleeding (1.8% vs. 9.2%, p < 0.001) during the index admission or within 30 days thereafter. No statistically significant differences in rates of pelvic abscess, stoma creation, or LOS were found between the two cohorts. Three sensitivity analyses to address the difference in conversion rates yielded largely consistent results, with loss of statistical significance for inpatient admission in some cases. This study is limited by its potential for differences in unmeasurable factors between the ECP trial and historical cohorts.ConclusionsIn this study, the ECP trial cohort had lower incidence proportions of several surgical complications as compared with the historical cohort. Further controlled prospective clinical studies are needed to confirm the validity of this finding.

Chemotherapy completion rate for locally advanced rectal cancer at a safety-net hospital.

e15597 Background: Patients with locally advanced rectal cancer (LARC) typically receive chemoradiation prior to surgery, followed by adjuvant chemotherapy (standard). Recently there has been a growing trend toward total neoadjuvant therapy (TNT), in which all chemotherapy is given in the neoadjuvant setting, having the advantage of higher chemotherapy completion rates. Data exploring adherence to both standard therapy and TNT within a vulnerable, underserved population is lacking. Within our safety-net hospital, we determined the chemotherapy completion rates for LARC patients who received TNT vs standard treatment. We also compared two populations within the standard treatment group- those who received all doses of prescribed adjuvant chemotherapy (AC) and those who did not. Methods: A retrospective chart review was performed for all patients with LARC (stage II or III) presenting to Los Angeles County + USC Medical Center from 2015 to 2020. Patients who progressed prior to receiving their first dose of chemotherapy and patients lost to follow-up were excluded. Patient demographics, stage, neoadjuvant/adjuvant treatment, operative characteristics, and postoperative course were abstracted. T-tests and Wilcoxon rank-sum tests were used to compare means and medians, respectively; chi-squared tests were used to compare categorical variables. Results: 67 patients were included- 59 in the standard group and 8 in the TNT group. Mean follow-up was 30 months. All patients in the TNT group completed neoadjuvant chemotherapy. In the standard treatment group, the overall AC completion rate was 81% (n = 48) (Complete Group). 19% (n = 11) did not receive all prescribed doses of AC (Incomplete Group). Compared to patients in the Incomplete Group, patients in the Complete Group were significantly older (mean age 55 vs 48, p = 0.017), had a shorter mean time interval from surgery to initiation of AC (9 weeks vs 13 weeks, p = 0.016), and were less likely to experience a delay in receiving AC &gt; 90 days (15% vs 46%, p = 0.022). In total, 12 patients (20%) in the standard group experienced a delay in AC, of which six (50%) were due to anastomotic leak and/or pelvic abscess. Three of those patients who experienced a delay (25%) required either drain placement or re-operation to address their complication. More patients in the Complete Group went on to have their temporary stomas reversed compared to those in the Incomplete Group (94% vs 70%, p = 0.031). Conclusions: While this population had a high AC completion rate, a meaningful proportion of all patients (though more in the Incomplete Group) experienced a delay in AC &gt; 90 days, with surgical complications responsible for the delay in half of these patients. In contrast, all patients who received TNT completed neoadjuvant chemotherapy. TNT may be a reasonable alternative to reduce therapy delays and further improve chemotherapy completion rates in an underserved population.

Long-term surgical outcomes after resection of presacral tumours and risk factors associated with recurrence.

The incidence of presacral tumours is low and pertinent data on the management and outcomes after surgery are sparse. The aim of this study was to identify the risk factors for recurrence in patients with presacral tumours undergoing surgery at our institution. Patients undergoing resection of a presacral tumour between 2009 and 2019 were identified from a prospectively maintained database. Demographics, clinicopathological features, preoperative imaging, operative details, morbidity, mortality, recurrence and survival were investigated. A total of 122 patients were identified. There were 95 women (77.9%) and the median age was 34years. The most common presenting symptoms included pelvic pain (n=60, 49.2%) and recurrent abscesses or fistulas (n=40, 32.8%). The accuracy of preoperative magnetic resonance imaging (MRI) in distinguishing malignant from benign tumours was 93.9%. Six patients underwent three-dimensional computed tomography angiography (3D-CTA) and preoperative interventional embolization. Procedures were performed using transabdominal (n=9), posterior (n=99) and combined abdominal and posterior (n=14) approaches. There were 21 (17.2%) malignant and 101 (82.8%) benign tumours. The local recurrence rate was 33.3% for malignant tumours and 9.9% for benign tumours. Multivariate analysis revealed that recurrence of malignant tumours was associated with R1 resection while recurrence of benign tumours was associated with secondary resections and intraoperative lesion rupture. Presacral tumours continue to be a diagnostic and therapeutic challenge. A multidisciplinary team, informed by modern imaging modalities, is essential for the management of presacral tumours.

A Series of Haemophilus parainfluenzae Surgical Infections and Review of the Literature.

Background: Haemophilus parainfluenzae (HPI) is a rare and underreported pathogen. Haemophilus parainfluenzae causes respiratory, soft tissue, and central nervous system (CNS) infections, and endocarditis. Little data on HPI surgical infections are available, especially for intra-abdominal infections (IAI). Patients and Methods: Haemophilus parainfluenzae isolates were recovered from patients treated at a rural hospital during a two-year period. Isolation and identification of the pathogen was done according to standard guidelines. A literature review with regard to HPI IAI was done. Results: A total of 273 HPI isolates were analyzed, 15 patients had double isolates; HPI was commonly part of a mixed infection. Respiratory tract infections accounted for 64.8%, ear-nose-throat (ENT)/eye infections for 17.9%, genital/urologic infections for 3%, blood stream infections for 1% of cases and 13.2% of HPI isolates involved surgical infections. Thirty-four patients (36 isolates) had HPI surgical infections including 28 skin/soft tissue infections, two bone infections, two perirectal abscesses, one infected hemodialysis catheter, and three IAIs including perforated appendicitis, perforated diverticulitis, and a pelvic abscess 10 days after laparoscopic appendectomy. All three IAIs were mixed infections and successfully managed with percutaneous drainage and antibiotic therapy. More than 90% of HPI isolates in our hospital tested negative for β-lactamase production. A literature review revealed 32 reported cases of HPI IAI including biliary infections (12), peritonitis (9), liver abscess (7), and IA abscess (4) with the majority being monomicrobial; treatment included antibiotic agents and surgery/intervention in most cases. Outcomes were generally favorable. Conclusions: Our study confirms data from the literature that HPI is capable of causing a variety of severe surgical infections. More research with regard to this pathogen is warranted.

Acute Ileo-jejunal Diverticulitis: a 10-Year Single-center Experience

Acute ileo-jejunal diverticulitis (AIJD) is a very uncommon entity with an unknown real prevalence. It usually presents non-specific symptomatology. There is no consensus on the optimal treatment due to the scarcity of studies on the subject. This study aimed to assess the clinical manifestations and short-term outcomes after conservative or surgical treatment for AIJD. A retrospective analytical study was conducted. A search for all patients diagnosed with AIJD in the period between 2009 and 2019 was performed in our center. Demographic, clinical, laboratory, and radiological data were collected. This study aimed to assess the differences between patients who received surgical treatment and those who received conservative treatment. We identified 24 patients with acute ileo-jejunal diverticulitis. A lower rate of surgical treatment was observed in patients with a higher age-adjusted Charlson comorbidity index (p = 0.038). There were no statistically significant differences in the demographic, clinical, laboratory, and radiological data according to conservative or invasive management, except in patients in whom an enterolith was identified in computed tomography. All those patients underwent surgical treatment (p = 0.027). A higher rate of conservative treatment failure was found at higher stages (Ib, II, and III) of the modified Hinchey classification. Mortality within 30 days of surgery was 12%. AIJD is an uncommon entity with significant mortality rates. In the presence of enteroliths, peri-intestinal or pelvic abscess, and generalized peritonitis, surgical treatment was mandatory. Conservative treatment may be an option in non-severe cases.

Abdominal radical trachelectomy as fertility-sparing management for early stages of cervical cancer: Our experience in 18 cases.

The aim of this study was to present our experience of 18 cases of abdominal radical trachelectomy (ART), including 5 performed during pregnancy, analyzing patient selection, surgical complications, and oncological and obstetrical outcomes. This reproductive study included all early stage cervical cancer patients referred for ART at the 1st Obstetrics and Gynecology Clinic of the Emergency Clinical County Hospital Targu Mures, between 2010 and 2020. A total of 19 women were considered for ART, and only 1 case required conversion to radical hysterectomy. The patient mean age was 31 years (range 24-38 years), and 66.67% of the patients were nulliparous. Six women (33.33%) had stage IA2, 4 (22.22%) had stage IB1, 5 (27.78%) had stage IB2, and 4 (22.22%) had stage IB3 disease. One intraoperative complication occurred in this series, which consisted in both right ureteral and bladder injuries. Early postoperative complications were represented by urinary bladder dysfunction (33.33%), symptomatic pelvic lymphocele (11.1%), peritonitis (5.5%), and wound infection (5.5%). Late postoperative complications included cervical stenosis (5.5%), amenorrhea (11.1%), and pelvic abscess (5.5%). Four out of the 18 patients were operated on during pregnancy between 14 and 20 weeks; 2 of them gave birth at term, 2 of them aborted shortly after the surgery. Two vaginal recurrences were recorded; both were managed by hysterectomy, partial colpectomy and adjuvant chemoradiotherapy. At this moment, all patients are alive with no evidence of disease and 3 of them managed to conceive. In conclusion, ART should be recommended as a fertility-preserving procedure for women in their reproductive age. In selected cases, ART can be performed during pregnancy with encouraging results.

Indocyanine Green Fluorescence Identification of Ureters in Robotic Hartmann Reversal

Introduction: Hartmann reversal is a complex surgical procedure associated with significant morbidity. Injuries of the urinary tract can occur in 10% to 15% of primary colorectal resections and complex reconstructive surgeries. Indocyanine green (ICG) intraureteral injection has been advocated recently for ureteral identification during pelvic surgery. Decreasing the rate of ureteral injuries directly impacts length of stay, costs, morbidity, and mortality rate. This video illustrates the utility of intraureteral ICG during a Hartmann reversal procedure in a complex pelvis. Materials and Methods: Intraureteral injection of ICG was used in five patients, three Hartmann reversals and two rectal bulky tumors. All patients underwent robotic procedures except one patient with a bulky and perforated rectal tumor combined with a left pelvic kidney. This specific video highlights a patient who underwent a laparoscopic Hartmann procedure for pelvic abscess caused by a perforated sigmoid diverticula. A Hartmann reversal was performed 2 months later. A robot-assisted Hartmann reversal was carried out and off-label bilateral intraureteral infusion of ICG was performed. A 5F ureteral catheter was inserted in both ureters before surgery, 10 cm beyond the ureteral orifice and then retracted back to 2 cm. When requested, 25 mg of ICG were dissolved in 10 mL of saline and injected into both ureters. ICG reversibly binds to proteins of the urothelial layer. ICG is a fluorescent dye, made of hydrophobic molecules that usually is injected intravenously and binds to plasma proteins and is excreted by liver. It becomes fluorescent when excited by the robotic laser light (Firefly Fluorescence Endoscope System; Intuitive Surgical, Inc., Silicon Valley in Sunnyvale, CA). Injection time was 15 minutes and ICG helped identify the right ureter that was slightly medialized and adherent to the rectal stump. A peristomal hernia was present and treated by direct suture after an adhesiolysis. After dissecting the rectal stump from the right ureter and pelvic wall, the rectal stump was re-transected and a colorectal end-to-end mechanical anastomosis was performed. A perianastomotic suction drainage was placed in the pelvis. Both ureteral catheters were removed at the end of the procedure. Results: Neither ureteral injuries nor ICG-related intraoperative and/or postoperative adverse events, nor renal failures were experienced in all the treated cases. A transient hematuria was observed in two patients. Conclusions: Use of intraureteral ICG may be a safe and helpful procedure to identify ureters in complex pelvic and colorectal surgery. It can serve as a valid tool in preventing iatrogenic ureteral injuries. No competing financial interests exist. Runtime of video: 7 mins 52 secs

Dorsal approach with tailored partial sacrectomy and gluteal V\u2013Y fasciocutaneous advancement flap for the management of recurrent pelvic sepsis; case report

BackgroundPelvic sepsis after surgery for rectal cancer is a severe complication, mostly originating from anastomotic leakage. Complex salvage surgery, during which an omentoplasty is often used for filling of the pelvic cavity, is seldomly required. If this fails, a symptomatic recurrent presacral abscess with a risk of progressive inflammation can develop. Such patients have often undergone multiple surgeries and have disturbed abdominal wall integrity, adhesion formation, and presence of one or two stoma(s). Subsequent salvage surgery via the conventional anterior abdominal approach is therefore less suitable. We describe three cases with a chronic presacral sinus and failure of first salvage surgery. All three patients underwent a prone only approach with tailored sacrectomy. This novel approach provided direct access to the pelvic abscess with optimal exposure for complete and safe debridement. A unilateral or bilateral gluteal V–Y fasciocutaneous advancement flap was created to completely fill the cavity with well vascularized tissue.Case presentationsThree male patients of 80, 66 and 51 years of age initially underwent low anterior resection with neo-adjuvant radiotherapy for rectal cancer. The first patients underwent intersphincteric resection of the anastomosis with omentoplasty 128 months after index surgery, and second salvage surgery 2 months later. The second patient underwent abdominoperineal resection with omentoplasty for locally recurrent rectal cancer, cystoprostatectomy with revision of the omentoplasty for pelvic sepsis 100 months after index surgery, and second salvage surgery 16 months later. In the third patient, the anastomosis was dismantled with subsequent intersphincteric proctectomy and omentoplasty 20 months after index surgery, and second salvage surgery was performed 93 months later. Second salvage surgery in all three patients was indicated because of symptomatic recurrent pelvic sepsis. Second salvage surgery consisted of sacrectomy, complete debridement of the presacral area, and filling with a gluteal advancement flap. This resulted in favorable postoperative recovery with ultimate healing of the pelvic cavity.ConclusionThe dorsal approach with tailored sacrectomy and gluteal V–Y advancement flap is a valuable option in highly selected patients to treat recurrent pelvic sepsis after multiple prior transabdominal interventions for chronic presacral sinus.

English

A 30-year-old female, gravida-3, para–1, live–1, abortion–1, admitted in Sri Ramachandra Institute of Higher Education and Research (SRIHER) at 37 weeks and 6 days of gestation–planned for elective lower segment Caesarean section. Growth scan done at 37 weeks showed fetal growth restriction (estimated fetal weight-EFW at 3rd centile) with uterine artery Doppler showing high resistance flow. She had mild anaemia (haemoglobin 9g / dl), B negative blood group, indirect Coomb’s test was negative, and injection anti D was not given antenatally. She had an uneventful antenatal period. In 2013, at 23-years of age, she was referred to SRIHER with high grade fever and lower abdominal pain for one-week duration. She had history of dilatation and curettage done one week back for missed abortion. Pelvic ultrasound and computed tomography showed an adnexal mass with air pockets suggestive of a pelvic abscess. She was taken up for emergency laparoscopy which revealed a pelvic abscess walled off by omental and bowel adhesions along with perforation on the upper part of the posterior surface of uterus with extensive sloughing. In view of the nulliparous status of the patient conservative management was opted for and decision was taken to preserve the uterus under stepped up antibiotic cover. Thorough peritoneal wash was given, and intraperitoneal drain was kept. Patient was intensively monitored. Though she developed features of evolving sepsis prompt critical care management resulted in her steady recovery without undergoing hysterectomy.1 In 2018, (G2A1) patient was planned for elective lower segment Caesarean section (LSCS) at 37 weeks. However, she came to our institute at 33 weeks and 4 days of gestation in early labour. In view of history of previous septic abortion with uterine perforation, she delivered by emergency lower segment Caesarean section. Baby was a late preterm girl, weighing 1.9 Kg, cried immediately at birth. Placenta and membranes were delivered in toto. Intraoperative period was uneventful. Posterior wall of uterus did not show any signs of the previous perforation. Postoperative period was uneventful.

Surgical management of endometriotic women with pregnancy intention in France: A national snapshot of centers performing a high volume of endometriosis procedures.

ObjectiveTo provide a snapshot of the surgical management of endometriosis in French high-volume activity centers. MethodsAnalysis of prospectively collected data between November 2015 and May 2017 in 21 centers with a high volume of endometriosis surgery in France. Each facility could include up to 40 patients undergoing laparoscopy for endometriosis. Data were collected before and two months after surgery. Results361 patients were enrolled in the study. Twenty-seven patients (7.48%) were lost to follow-up at the month 2 visit. Endometriosis stage was I-II in 33.70% of patients and III-IV in 66.30%. Uterosacral ligament resection was the most frequently performed procedure (50.97%) followed by rectal surgery (31.58%), ovarian procedures for endometrioma, procedures for ureters (21.33%) and the bladder (11.91%). Antiadhesion agents were employed in 215/361 (59.56%) patients. The median length of hospital stay after surgery was 2 (IQR 1 – 4) days. Post-operative complications were recorded in 9.34% of patients. Rectovaginal fistulae occurred in 8 patients (2.41%), pelvic abscess in 4 (1.20%) and bladder atony in 3 (0.90%). 17 patients (5.14%) required a second surgical procedure after a median time of 31 days (IQR 9 – 81). Two months after surgery, 95.09% of patients reported being satisfied or very satisfied with the surgery. ConclusionOur study shows that surgical management of endometriosis in centers with a high volume of endometriosis surgery, mainly concerns women presenting with severe disease and deep localizations, with an overall risk of major complications inferior to 10% and a high rate of patient satisfaction.

78. Case Series: PID in Never Sexually Active Girls with Vaginal Voiding

<h3>Background</h3> Pelvic inflammatory disease (PID) is an inflammatory disease of the upper reproductive tract primarily seen in sexually active women and often associated with sexually transmitted infections (STI). Studies demonstrate PID occurs in never sexually active girls with concomitant gastrointestinal infections or anatomical genitourinary abnormalities. We present two cases of PID attributable to vaginal voiding in never sexually active girls. <h3>Case</h3> Patient A was an 11 year old girl who presented to an outside hospital with a four day history of fever and right lower quadrant pain. Her medical history was significant for obesity and constipation. Physical exam demonstrated fever, tachycardia and diffuse abdominal tenderness with peritoneal signs. CT demonstrated a pelvic abscess. She was transferred to our facility and evaluated by Pediatric Surgery. She underwent pelvic exam under anesthesia which demonstrated purulence and diagnostic laparoscopy with drainage of a right tubo-ovarian abscess (TOA). Gynecology was consulted postoperatively. There was no disclosure of sexual abuse, and STI screening was negative. Further discussion revealed a long history of dysfunctional voiding and urine leakage. Patient B was a 9 year old girl who presented as a transfer to our pediatric hospital with fever, left lower quadrant abdominal pain and imaging findings consistent with left pyosalpinx. Gynecology was consulted. Her history was significant for obesity, constipation, malodorous urine and urinary incontinence. STI screening was negative, and she made no disclosure of sexual abuse. Physical exam revealed diffuse abdominal tenderness as well as urine trapping in the vagina. <h3>Comments</h3> PID and TOA have been demonstrated to occur in never sexually active patients. Evaluation of these patients should include a thorough social history to rule out the possibility of undisclosed sexual abuse and STI screening. Once a sexual mode of transmission is safely ruled out, clinicians must consider other infection risk factors. We present two patients with a history of dysfunctional voiding resulting in trapping of urine in the vagina. We hypothesize that urine trapping led to an ascending pelvic infection. It is important to recognize dysfunctional voiding as a risk factor for pelvic infection so patients may receive appropriate treatment as well as provide a better understanding of their diagnosis. Counseling regarding healthy bladder habits, voiding techniques for prevention of urine trapping and consultation with Urology and pelvic floor Physical Therapy when appropriate are important interventions to prevent recurrence. Treatment of this underlying condition can not only help reduce future risk of ascending infection but improve quality of life.

A199 SEVERE COLITIS FOLLOWING PELVIC RADIOTHERAPY: CASE REPORT AND REVIEW OF THE LITERATURE

Abstract Background Mild-to-moderate proctocolitis is a well-known complication of pelvic radiation therapy, occurring in 43% and 6% of patients following external beam radiotherapy (EBRT) and brachytherapy (BT), respectively. This typically presents as recurrent painless rectal bleeding, diarrhea, urgency, and/or iron-deficiency anemia. Severe ulcerating proctocolitis is a less common complication of pelvic radiotherapy and is rare following BT. We report two cases of severe ulcerating proctocolitis mimicking inflammatory bowel disease (IBD) following pelvic radiotherapy in patients without known IBD, including an elderly male undergoing EBRT, and an elderly female undergoing vaginal vault BT. Aims To describe two cases of severe ulcerating proctocolitis, mimicking IBD, following pelvic radiotherapy. Methods Case descriptions and literature review. Results A 71-year-old male without antecedent gastrointestinal disease developed bloody diarrhea 3 months following EBRT for treatment of prostate cancer. Infectious work-up was negative. Blood work showed anemia and an elevated CRP. CT scan showed distal large bowel inflammation concerning for proctocolitis. Flexible sigmoidoscopy revealed severe proctosigmoiditis with circumferential thickening and nodularity of the mucosa and multiple ulcers. Biopsies showed ulcer tissue with fibrinopurulent exudate. He was treated with systemic corticosteroids and symptoms gradually resolved. Repeat colonoscopy 8 months later showed healed inflammation with scarring and residual radiation proctosigmoiditis. A 74-year-old female without antecedent gastrointestinal disease developed watery diarrhea 2 weeks after initiating low dose vaginal vault BT for treatment of endometrial cancer. Infectious work-up was negative. Blood work showed an elevated CRP and CT scan revealed proctocolitis extending to the descending colon. Flexible sigmoidoscopy revealed severe ulcerating proctosigmoiditis with tram tracks of denuded mucosa. Biopsies showed moderate diffuse chronic active colitis with crypt abscesses and apoptotic bodies. She was treated with systemic corticosteroids followed by infliximab and methotrexate, with mild symptomatic improvement. However, repeat endoscopy revealed persistent severe ulceration. Unfortunately, she developed a sigmoid perforation with pelvic abscess, leading to bacteremia and fungemia, and subsequently passed. Conclusions While rare, severe ulcerating proctocolitis mimicking IBD can occur following pelvic radiotherapy, including BT. The decision to manage these patients as IBD using immunosuppressive therapy should be weighed against the risks of these therapies, considering a patient’s age and underlying health, and in collaboration with a patient’s health care team. Careful assessment for risk factors and pathological findings from biopsy specimens may help in predicting the likelihood of IBD in such patients. Funding Agencies None

Safety of Transrectal or Transvaginal Drainage of Pelvic Abscesses

AbstractObjective The literature on the safety and long-term sequelae of transrectal and transvaginal drainage of pelvic abscesses is limited. We evaluated the outcomes and safety of pelvic abscess drainage by interventional radiology at our institution.Methods After obtaining institutional review board approval, we retrospectively evaluated the outcomes of transrectal and transvaginal pelvic abscesses drainage using computed tomography, endorectal ultrasound, and or fluoroscopy.Results The study included 26 patients, with an age range of 24 to 88 years old, out of whom 53.8% were men. A total of 46.1% of the participants were African Americans and 26.9% were Caucasians. The average body mass index was 28.4 (range: 15.6 to 41.9). The most common etiology was penetrating abdominal injury (27%), followed by appendectomy (23%), diverticular disease (11.5%), anastomotic leak (11.5%), and disorders of gynecological causes (11.5%). The mean abscess diameter was 6.3 cm (range: 3.3 to 10.0 cm). Transrectal drainage was performed in all except one patient who had a transvaginal drainage. Transrectal ultrasound was used for drainage in 92.3% cases, and fluoroscopy was used as an additional imaging modality in 75% of the cases. An 8- or 10-Fr pigtail catheter was used in &gt; 80% of the patients. Drains were removed between 2 and 7 days in 92.3% of the cases. The average follow-up was 30.4 months (range: 1 to 107 months), and no long-term complications were reported. Only one patient required subsequent operative intervention for an anastomotic leak.Conclusions Pelvic abscess drainage by transrectal route using radiological guidance is a safe and effective procedure.

Dienogest reduces endometrioma volume and endometriosis-related pain symptoms

This study aimed to evaluate the efficacy and adverse effects of dienogest for the treatment of endometriomas. Dienogest (2 mg/day) was administered to patients with endometrioma continuously through the 6-month study period. The patients were prospectively examined on the efficacy and side effects at baseline, at third months, and sixth months of the treatment. Twenty-four out of 30 patients were able to complete the study. The mean volume of the endometrioma decreased significantly from 112.63 ± 161.31 cm³ at baseline to 65.47 ± 95.69 cm³ at a 6-month follow-up (−41%) (p = .005). The VAS score for pelvic pain decreased significantly from 7.50 to 3.00 (p < .001) at the sixth months of treatment. The most common side effects were menstrual irregularities. Laboratory parameters did not change during the study. Dienogest considered being effective for 6 months of use in decreasing the size of endometrioma, reducing endometriosis-associated pain with a favourable safety and tolerability profile. Impact statement What is already known on this subject? Laparoscopic excisional surgery for endometrioma is currently the most valid approach in the treatment of endometriomas. However, there are concerns about ovarian reserve damage during surgery. What do the results of this study add? Dienogest considered being effective in decreasing the size of endometrioma, reducing endometriosis-associated pain with a favourable safety and tolerability profile. Long-term use of dienogest in younger patients with endometriomas who are yet to give birth may reduce the possibility of surgery by reducing the size of the endometriomas and may preserve ovarian reserve. What are the implications of these findings for clinical practice and/or further research? Dienogest may reduce the incidence of infectious complications such as pelvic abscess after oocyte retrieval and the surgical procedures in infertile patients with endometrioma.

Bowel obstruction due to Chlamydia trachomatis: a case report and review of literature

BackgroundChlamydial infection is a difficult-to-diagnose type of sexually transmitted disease that occurs mainly in young people. We report a case of bowel obstruction caused by intrapelvic adhesions formed by chlamydial infection.Case presentationThis patient was a 23-year-old woman who had been suffering from acute abdominal pain. She had been previously treated several times for intrapelvic abscesses and had a history of chlamydial infection. Endometriosis was thought to be the cause of her pelvic abscess based on endoscopic findings. Computed tomography demonstrated a small bowel obstruction caused by a pelvic abscess. However, the diagnosis could not be confirmed. She underwent laparoscopic surgery and was diagnosed with bowel obstruction due to adhesion of chlamydial infection based on the intraoperative findings and Chlamydia trachomatis antibody test. She was discharged 5 days after surgery.ConclusionsIt is necessary to consider the possibility of chlamydial infection as a cause for lower abdominal pain and unexplained bowel obstruction in female patients.

773 Risk factors for adverse maternal outcomes following expectantly managed preterm prelabor rupture of membranes

Preterm prelabor rupture of membranes (PPROM) counseling often focuses on fetal risks. We sought to characterize maternal risk following PPROM and determine factors associated with maternal morbidity. Nested case control study of women with PPROM at a single institution from 2013–2019 admitted at >23 weeks gestational age (GA). Pregnancies complicated by latency < 24 hours, fetal anomalies, higher order multiples, IUFD, and PPROM within 2 weeks of chorionic villus sampling/amniocentesis were excluded. Cases were defined as women with maternal morbidity including: death, sepsis, ICU admission, acute kidney injury (AKI), postpartum (PP) D&C, PP hysterectomy, venous thromboembolism (VTE), PP hemorrhage (PPH), PP wound complication, PP endometritis, pelvic abscess, PP pneumonia, readmission, and/or need for blood transfusion. Controls were women without above morbidities. Severe morbidity was defined as: death, ICU admission, VTE, AKI, PP hysterectomy, sepsis, and/or transfusion >2 units. Demographics, antenatal and delivery characteristics were compared between cases and controls. Bivariate statistics and regression models were used to compare outcomes and calculate adjusted odd ratios, respectively. Of 361 included women, 64 women (17.7%) experienced maternal morbidity and 9 (2.5%) had severe morbidity. Other morbidities are listed in Table 1. Cases were more likely to be older, have private insurance, have BMI >40, have chorioamnionitis at delivery, and undergo cesarean or operative vaginal delivery (Table 2). Admission GA and latency did not differ (Table 2). After controlling for confounders, cesarean delivery, BMI >40 at admission, private insurance, and tobacco use were associated with increased odds of maternal morbidity (Table 2). In this cohort, maternal morbidity occurred in more than 1 of 6 women with PPROM. Private insurance, BMI >40, tobacco use, and cesarean delivery were associated with higher odds of morbidity. These data can be used in counseling and to advocate for smoking cessation among women admitted with PPROM.View Large Image Figure ViewerDownload Hi-res image Download (PPT)