Late-Onset Ileocutaneous Fistula Eight Years After Plug Repair With Polypropylene Mesh: A Case Report

Introduction: As one of the short-term complications after inguinal hernia repair, mesh infection frequently occurs but rarely leads to ileocutaneous fistula. We present a rare case of ileocutaneous fistula 8 years after inguinal hernia plug repair with polypropylene mesh.Case Presentation: The patient was a 67-year-old male who underwent a plug repair with polypropylene mesh of the right inguinal hernia. Eight years after the primary repair, skin ulceration with pus presented in the right groin area, and the final diagnosis was enterocutaneous fistula. According to laparoscopic exploration, the ileum below the fistula closely adhered to the abdominal wall. After gently separating the bowel loop, a defect area of about 2 × 3 cm was observed on the surface of the ileum. In laparotomy, the plug was found embedded in the ileum and then was completely removed, and an ileum side-to-side anastomosis was performed. The patient was discharged 2 weeks after the surgery, and follow-up at the sixth month revealed complete healing of the wound and no evidence of hernia recurrence.Conclusion: Late-onset ileocutaneous fistula should be considered in the differential diagnosis in patients who present inflammation and abscess formation after hernia repair. Besides, for patients with suspected intestinal fistula after hernia repair, laparoscopic exploration should be given priority, and the mesh removal approach should be tailored according to the results of laparoscopic exploration.

P126 LAPAROSCOPIC TREATMENT OF HYDROCELE IN FEMORAL CANAL: A CASE REPORT

Aim The hydrocele of the femoral canal (Femorocele) is one of the rarest entities of femoral hernia (1). All of the reported cases were an intraoperative diagnosis and were treated with an open approach. We are reporting, the probably first femorocele diagnosed and treated laparoscopically. Material and Methods A 57-years-old female patient was presented in our outpatient clinic with pain and an unclear lump in the groin area for 6 months. The sonographic examination revealed a cystic structure in the groin area resampling Nuck’s cyst. An elective laparoscopic exploration and transabdominal preperitoneal (TAPP) repair was planned. Results A laparoscopic exploration was carried out. Intraoperatively, the cystic structure was not found in the Nuck’s Canal, but in the femoral canal as a content of a femoral hernia with some pre-peritoneal fat. By the extraction of the cyst, a gush of clear fluid was noted. After the usual preparation of the preperitoneal area, a mesh was placed in TAPP technique. Conclusions This rare variety of femoral hernias, femorocele, is commonly misdiagnosed as a strangulated hernia or Nuck’s cyst (as in this case) among other differential diagnoses (2). All published femorocele cases were treated with an open approach. As demonstrated here, such unclear cases can be laparoscopically explored and treated accordingly.

Pelvic congestion syndrome and May-Thurner syndrome as causes for chronic pelvic pain syndrome: neuropelveological diagnosis and corresponding therapeutic options

Objective: To report on diagnosis and management of pelvic congestion including the May-Thurner syndrome (MTS) as potential etiologies for intractable pelvic neuropathic pain. Design: Retrospective study of women presented with intractable pelvic neuropathic pain, who had left sided venous uterine plexus above 6mm with reversed and slow flow on Doppler, with dilated arcuate veins passing through the uterine muscle. Those with suspicion of MTS underwent further radiological investigations and if applicable, endovascular interventions. Setting: Tertiary referral unit specialized in advanced gynaecological surgery and neuropelveology. Intervention: 61 consecutive patients were included. 14 with visceral pain presumed to be caused by Pelvic Congestion Syndrome were treated by ovarian vein embolization. An improvement of pain was observed in all patients – mean pain reduction of 3.93 points, from 7.21 (±1.42; 4-10) to 3.28 pts (±1.54; 1-6) over 6 months (p<0.01). 47 presented with pelvic somatic neuropathic pain; 19 underwent endovascular intervention (angioplasty, stenting) and finally all of them a laparoscopic exploration/decompression of the sacral plexus and the endopelvic portion of the pudendal nerves, with an overall VAS reduction from 8.56 (±1.1712;7-10) to 2.63 (±1.53; 0-6) at one-year-follow-up (p<0.01). Conclusion: Laparoscopic exploration/decompression of the nerves seems to be effective in a carefully selected group of patients. Endovascular interventions for pelvic somatic neuropathies may not be an effective treatment. We recommend that Doppler studies of the uterine vessels are performed as an extension to gynaecological examination in women with intractable pelvic pain.

Strengthening the Construction of Pathology Department of Chinese Primary Hospitals is an Urgent Task

Background: pseudomyxoma peritonei(PMP) is a rare disease, the incidence of occult, mainly occurs in the appendix, ovary, etc., generally speaking, the progress is slow, through imaging diagnosis is more difficult, and the symptoms are not typical, often found in abdominal exploration, the treatment effect is relatively poor. Because PMP is often secondary to appendectomy, it is particularly important to make a careful pathological examination of the specimen after appendectomy. Case presentation: This case is a middle-aged and elderly man. Seven years after appendectomy, the specimen was confirmed as PMP by pathology after laparoscopic exploration. Later, the specimen 7 years ago was reexamined and pathological examination showed that the tumor was composed of mucinous cells. Conclusions: This puts forward higher requirements for the construction of pathology department in China's primary hospitals.

Circulating tumor DNA as a noninvasive marker of resectability in ovarian carcinomas.

5548 Background: Ovarian cancer is the leading cause of death by gynecological cancer. Complete surgery remains one of the main prognostic factors. Laparoscopic exploration is mandatory to assess surgical resectability at diagnosis or after neoadjuvant chemotherapy. However, there is no clinical or biological marker that can correctly predict resectability and may be able to avoid a second laparoscopic exploration for initially unresectable diseases. Our aim was to assess circulating tumor DNA (ctDNA) value as a predictive non-invasive marker of evolution towards resectability for patients with epithelial ovarian cancer receiving first-line chemotherapy. Methods: We explored in this work one of the secondary objectives of the CIDOC study (NCT03302884). CIDOC is a multicenter prospective study aiming to explore ctDNA value as early marker of disease relapse after first-line treatment for epithelial ovarian cancer. Patients with mucinous histology or early stages not requiring chemotherapy are excluded. Plasma samples are collected at diagnosis, during neoadjuvant chemotherapy, and during follow-up. After DNA extraction, panel-based next generation sequencing is performed on both tumor samples and germline DNA, and somatic mutations of interest are selected for ctDNA monitoring. ctDNA analyses are conducted using droplet digital PCR (BioRad QX200) by measuring the variant allele fraction (VAF) of previously identified mutations. Results: This intermediary analysis has included 47 patients diagnosed between March 2017 and December 2019. Median age was 69 years old (48 – 84). Most of the patients had advanced disease (89.4% stage FIGO III or IV), serous histology (94.8%), and high grade tumor (92.3%). Most of the patients underwent complete interval cytoreductive surgery (76.3% vs 17.4% complete upfront surgery). Most of the tumors had TP53 mutations (85.1%), following by alterations involving DNA repair genes (38.3%). Median cell-free DNA concentration at baseline was 0.38 ng/µL (0 – 12.8). ctDNA was identified in 92.1% of patients at baseline with a median VAF of 1.84% (0 – 42.52%). ctDNA VAF was correlated to the peritoneal dissemination ( p= 0.039) assessed with the peritoneal cancer index. ctDNA clearance after preoperative chemotherapy tended to be correlated to achievement of complete interval surgery for patients receiving neoadjuvant chemotherapy ( p= 0.108). Conclusions: ctDNA may be a promising non-invasive marker to assess peritoneal cancer spreading and to predict surgical resectability after neoadjuvant chemotherapy. If confirmed in larger populations, this may enable to avoid additional surgical explorations for patients who remain ctDNA positive after chemotherapy. Clinical trial information: NCT03302884.

Laparosacopic management with combination of fatty meal and methylen-blu for chylous leak after a left para-aortic paraganglioma excision

We report a case of chylous leak recognized post-operatively after abdominal surgery for left para-aortic paraganglioma in a young female with a history of open botallo’s duct. Conservative measures failed to control the leak and the patient is not eligible for sclerotisation. Laparoscopic exploration with intralipidand methylen blue injection through an orogastric tube revealed the leaking area near the superior mesenteric vein behind the Traitz, and this was ligated with non-asorbable suture and placement of acrylic glue. The patient was discharged the 7th post-operative day after removal of the drainage which appeared to supply &lt;100 cc of serum material. Outpatient control was successful and the patient is actually in good conditions.