Önder Sürgit

Endometriosis of rectosigmoid colon mimicking gastrointestinal stromal tumor

Case Report Turk J Surg 2018 DOI: 10.5152/turkjsurg.2017.3730 Cite this paper as: Kafadar MT, Çaviş T, Sürgit Ö, Köktener A. Endometriosis of rectosigmoid colon mimicking gastrointestinal stromal tumor. Turk J Surg 2018; 10.5152/ turkjsurg.2017.3730 genital organs and pelvic peritoneum, but it also rarely affects gastrointestinal system (GIS), lungs, mesentery, urinary bladder, greater omentum, surgical scars, skin, kidneys, and nasal cavity. In the GIS, endometriosis usually involves the rectosigmoid junction (74%) followed by ileum and appendix (4). Intestinal endometriosis is usually asymptomatic but may lead to gastrointestinal bleeding, abdominal cramps, nausea, vomiting, diarrhea, constipation, and intussusception. Symptoms alone are not diagnostic (5). Our patient had severe abdominal pain and bloating. Gastrointestinal stromal tumor is the most common mesenchymal tumor of the GIS. It originates from Cajal interstitial cells found in myenteric plexus and smooth muscle cells of the GIS. It usually affects people older than 40 years of age. It may appear anywhere in the GIS, although it frequently involves the stomach (39%-70%) and small intestine (20%-32%), but albeit rarely, colon, rectum (5%), esophagus (2%), and appendix. GIST is usually asymptomatic in its early stages. In advanced cases, it most commonly gives rise to abdominal pain (50%-70%), gastrointestinal bleeding (20%-30%), and a palpable abdominal mass. Its diagnosis is usually achieved by CT and magnetic resonance imaging (MRI). Also, a submucosal mass may be revealed by GIST endoscopy or colonoscopy, a regular-border filling defect by double-contrast colonic X-Ray, or a hypoechoic lesion originating from muscularis propria by endoscopic ultrasonography (6). Endometriosis usually involves serosa or subserosa, although it may involve all layers of colon simultaneously. It may rarely appear as a nodular mass infiltrating the intestinal wall. In the presence of a deep invasion by lesions, it may falsely be interpreted as colon cancer, Crohn disease, or carcinoid tumor. Furthermore, it may incite inflammation and fibrosis within the intestine, leading to luminal narrowing and obstruction in time. As a result, intestinal obstruction and perforation may occur (7). As for GIST, diagnosis can be achieved by ultrasonography, CT, MRI, and colonoscopy, depending on the localization of the lesion. Although radiological imaging techniques cannot always provide a definitive diagnosis, they can still inform about a lesion’s size, localization, and depth. Submucosal mass lesions protruding into the lumen and covered by normal mucosa seen in colonoscopy may be of intramural or extramural origin. Lipoma, lymphangioma, carcinoid tumor, GIST, and leiomyoma are examples of intramural lesions, whereas peritoneal carcinomatosis and extracolonic tumor invasions are examples of extramural neoplasms. Non-neoplastic intramural lesions include lymphoid hyperplasia, hematoma, vascular lesions, pneumatosis cystoides coli, whereas extramural lesions include endometriosis (8). Because the clinical presentation of patients with intestinal endometriosis may be confused with many disorders including malignant conditions, diagnosis may be delayed and difficult. Fine-needle biopsy is helpful for making the diagnosis, although surgery and histopathological examination of the surgical excision material are usually required for a definitive diagnosis and to rule out a malignancy. Most intestinal endometriosis cases are diagnosed at laparoscopy or laparotomy (9). Our case could similarly not be diagnosed in preoperative phase. Despite the lesion’s resemblance to a GIST for its rectosigmoid involvement pattern, tomographic findings, and rectosigmoidoscopic appearance, it received a definitive diagnosis after a pathological examination of the laparoscopically excised lesion from the rectosigmoid junction. Kafadar et al. Endometriosis of rectosigmoid colon Figure 1. Axial contrast-enhanced CT shows a mass lesion in the rectosigmoid region. The mass is indiscernible from intestinal wall, it is mildly enhanced by I.V. contrast agent, and it causes no obstruction Figure 2. a, b. Endometrial stroma and endometrial glands between submucosa and muscle fibers of muscularis propria (a, b) (H&E:100x, H&E:200x) a b Various hormone suppression therapies previously applied for intestinal endometriosis usually proved unhelpful. Patients who cannot be operated for any reason can be medically managed by non-steroidal anti-inflammatory drugs, danazol, gonadotropin-releasing hormone, and oral contraceptives. The majority of patients with this condition display significant improvement, although recurrences are common when therapy is stopped. Hence, surgery should particularly be the first option in younger patients and those with severe symptoms. Resection of the affected intestinal segment and re-anastomosis of the intact parts is the best accepted approach for intestinal endometriosis. Recurrence rates remain low after total excision (10). CONCLUSION In women of reproductive age, intestinal endometriosis, even if asymptomatic, should be included in the differential diagnosis of submucosal lesions of the rectosigmoid colon in addition to GISTs and carcinoid tumors. This rare condition may mimic many other disorders. Definitive diagnosis is only possible through surgical resection and histopathological examination of lesions. Informed Consent: Written informed consent was obtained from patient who participated in this study. Peer-review: Externally peer-reviewed. Author Contributions: Concept M.T.K.; Design M.T.K., T.Ç.; Supervision M.T.K., A.K.; Resource M.T.K., Ö.S., A.K.; Materials M.T.K., T.Ç.; Data Collection and/or Processing M.T.K., Ö.S.; Analysis and/or Interpretation M.T.K., Ö.S.; Literature Search M.T.K., T.Ç.; Writing Manuscript M.T.K.; Critical Reviews M.T.K., A.K. Conflict of Interest: No conflict of interest was declared by the authors. Financial Disclosure: The authors declared that this study has received no financial support. REFERENCES 1. Spaczynski RZ, Duleba AJ. Diagnosis of endometriosis. Semin Reprod Med 2003; 21: 193-208. [CrossRef] 2. Eskenazi B, Warner ML. Epidemiology of endometriosis. Obstet Gynecol Clin North Am 1997; 24: 235-258. [CrossRef] 3. Nezhat F, Shamshirsaz A, Yildirim G, Nezhat C. Pelvic pain, endometriosis, and the role of the gynecologist. In: Altcheck A and Deligdisch L eds. Pediatric, Adolescent and Young Adult Gynecology. 1st ed. New Jersey: WileyBlackwell, 2009: 174-194. [CrossRef] 4. Remorgida V, Ferrero S, Fulcheri E, Ragni N, Martin DC. Bowel endometriosis: presentation, diagnosis and treatment. Obst Gynecol Surv 2007; 62: 461-470. [CrossRef] 5. Bartkowiak R, Zieniewicz K, Kaminski P, Krawczyk M, Marianowski L, Szymanska K. Diagnosis and treatment of sigmoidal endometriosis-a case report. Med Sci Monit 2000; 6: 787-790. 6. Sturgeon C, Chejfec G, Espat NJ. Gastrointestinal stromal tumors: a spectrum of diseases. Surg Oncol 2003; 12: 21-26. [CrossRef] 7. Yıldırım S, Nursal TZ, Tarım A, Torer N, Bal N, Yıldırım T. Colonic obstruction due to rectal endometriosis: report of a case. Turk J Gastroenterol 2005; 16: 48-51. 8. Sassi S, Bouassida M, Touinsi H, Mighri MM, Baccari S, Chebbi F, et al. Exceptional cause of bowel obstruction: rectal endometriosis mimicking carcinoma of rectuma case report. Pan African Medical Journal 2011; 10: 33. 9. Erkan N, Haciyanli M, Sayhan H. Abdominal wall endometriomas. Int J Gynaecol Obstet 2005; 89: 59-60.[CrossRef] 10. Verspyck E, Lefranc JP, Guyard B, Blondon J. Treatment of bowel endometriosis: A report of six cases of colorectal endometriosis and a survey of the literature. Eur J Obstet Gynecol Reprod Biol 1997; 71: 81-84. [CrossRef] Turk J Surg 2018

Use of fibrin glue in preventing pseudorecurrence after laparoscopic total extraperitoneal repair of large indirect inguinal hernia

Purpose Seroma is among the most common complications of laparoscopic total extraperitoneal (TEP) for especially large indirect inguinal hernia, and may be regarded as a recurrence by some patients. A potential area localized behind the mesh and extending from the inguinal cord into the scrotum may be one of the major etiological factors of this complication. Our aim is to describe a novel technique in preventing pseudorecurrence by using fibrin sealant to close that potential dead space. Methods Forty male patients who underwent laparoscopic TEP for indirect inguinal hernia with at least 100-mL volume were included in this prospective clinical study. While fibrin sealant was used to close the potential dead space in the study group, nothing was used in the control group. The volume of postoperative fluid collection on ultrasound was compared between the groups. Results Patient characteristics and the volumes of hernia sac were similar between the 2 groups. The mean volume of postoperative fluid collection was found as 120.2 mL in the control group and 53.7 mL in the study group, indicating a statistical significance (P < 0.001). Conclusion Minimizing the potential dead space with a fibrin sealant can reduce the amount of postoperative fluid collection, namely the incidence of pseudorecurrence.