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Cancer of unknown primary is a challenging entity. We present an elderly woman with metastatic cancer of unknown primary despite comprehensive imaging and immunohistochemical analysis. Based on a thorough history, a gastrointestinal source was suspected and a diagnosis of pancreatic cancer concealed within a type IV hiatal hernia was made using multimodal imaging. On review of prior imaging, due to the highly complex anatomy within our patient’s hiatal hernia, the pancreatic mass was retroactively noted. While initial imaging may detect metastatic disease, identifying the primary malignancy requires a thorough history and physical examination, multimodal imaging where malignancy is suspected, and immunohistochemical analysis of metastatic deposits. Herniation of pancreatic cancer has not been previously described in the literature and serves as an important reminder of the importance of multimodal imaging in patients with significantly complex anatomy.

Peritoneal adhesion formation is a challenging postoperative complication. We aim to evaluate the effect of orally administered sirolimus, prednisolone, and their combination to prevent this entity.Eighty female albino underwent intraperitoneal injection of 3 mL of 10% sterile talc solution to induce peritoneal adhesion, and were subsequently and randomly divided into four groups (each n = 20); including a control group; 1 mg/kg oral prednisolone daily in the morning; 0.1 mg/kg oral sirolimus daily; and a combination group which received both drugs, with the same dosage. On the 29th day, abdominal cavities were explored, and classification was done based on Nair classification.All rats were healthy on the 29th day, in which exploration was performed. The rats in the control group had extensive intra-abdominal adhesions, while 17 (85%) rats in the control group had substantial adhesion; however, the prednisolone, sirolimus, and combination group had lesser adhesion formation. Also, 14 (70%) rats of prednisolone group, 13 (65%) of sirolimus group, and 16 (80%) of combination group had insubstantial adhesion. The decrease in the grade of peritoneal adhesion bands was highly significant in the combination group (P 0.001).The combination of sirolimus and prednisolone was effective for preventing peritoneal adhesions in rats.

Polypoid endometriosis is a rare variant of endometriosis and may mimic malignancy. The purpose of this study is to evaluate magnetic resonance (MR) imaging characteristics of polypoid endometriosis for the differential diagnosis with malignancy.MR imaging findings of four histologically proven polypoid endometriosis were retrospectively evaluated with the review of the literature.All polypoid endometriosis exhibited high signal intensity on T2-weighted images reflecting abundant dilated endometrial glands. Peritoneal lesions were surrounded by low signal intensity rim represented the "black rim sign" reflecting endometriotic fibrous adhesion. Two cases arising from endometriotic cysts showed transmural extension (peritoneal extension and myometrial infiltration). Endometriotic hemorrhagic foci were demonstrated in four lesions as high signal intensity on T1-weighted images and/or susceptibility-induced signal voids on susceptibility-weighted MR sequence. Diffusion-weighted images showed high signal intensity with relatively high apparent diffusion coefficient (ADC) due to T2 shine-through effect but no diffusion restriction, and dynamic contrast-enhanced (DCE) MR imaging showed gradually increasing contrast-enhancement pattern like benign pathologies.Polypoid endometriosis may mimic malignancy; however, black rim sign may be a characteristic MR imaging finding for the peritoneal lesions, and no diffusion restriction and gradually increasing contrast-enhancement pattern may reflect its benign nature.

Colorectal cancer with peritoneal involvement is traditionally recognized as having a poor prognosis, with treatment initially limited to palliative systemic chemotherapy alone. The introduction of cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy drastically altered the course of this disease entity and has demonstrated improvements in survival outcomes. Recent evidence has shown benefit of CRS but did not show benefit of HIPEC. Under the guidance of a multidisciplinary team and for appropriately selected patients, CRS is a key component of treatment that can positively alter the course of disease outcomes for patients with peritoneal involvement.

Primary omental torsion (POT) is a rare condition in children often misdiagnosed because of a lack of clinical manifestations. Here we present insights gained from the treatment of pediatric POT cases at a single center over 8 years and summarize some influencing factors found in diagnosis and treatment, in order to reduce the misdiagnosis of POT in children in the future.Demographic and clinical data of 17 children with POT treated in Shanghai Children's Hospital, Shanghai Jiaotong University from June 2012 to December 2020 were reviewed.The mean age of the 17 pediatric patients was 7.65 ± 2.12 years (range: 4-12 years), sixteen were male. The average time from the pain onset to operation was 73.82 ± 47.21 h (range: 21-144 h). In 5 cases, the ultrasound scan revealed a low-intensity inflammatory mass in the abdominal cavity. Only 1 of the 17 patients had normal body mass index, while others were overweight or obese. The mean computed tomography (CT) value of the mass in the lower right abdomen was - 58.74 ± 10.32 HU (range: - 70 to - 46 HU), which is close to that of its own abdominal wall fat [- 46.29 ± 9.45 HU (range: - 62 to - 32 HU)]. The location of the mass was located in front of the right colon in ten cases, except for two cases near the ligamentum teres. Five patients had whirl sign on CT images and 8 patients had pelvic fluid. Five cases were diagnosed as acute appendicitis and 12 were diagnosed as POT, the preoperative diagnosis was correct in 70.59% of cases. All 17 patients were treated with laparoscopic omentectomy. The average duration of hospitalization was 5.53 ± 1.12 days (range: 4-8 days). All cases were followed up. 1 case relapsed 8 months post operation, while the remaining cases had no complications.POT is rare in children with acute abdominal pain, which is more common in obese boys. The fatty mass in front of colon and between rectus abdominis sheath in CT image is specific, which is helpful for diagnosis of POT. Laparoscopy is an effective method for the treatment of POT in children.

The peritoneum is a unique serosal membrane, which can be the site of primary tumors and, more commonly, secondary pathologic processes. Peritoneal carcinomatosis is the most common malignant condition to affect the peritoneal cavity, and the radiologist plays an important role in making the diagnosis and assessing the extent of disease, especially in sites that may hinder surgery. In this review, we address the role of the radiologist in the setting of peritoneal pathology, focusing on peritoneal carcinomatosis as this is the predominant malignant process, followed by revising typical imaging findings that can guide the differential diagnosis. We review the most frequent primary and secondary peritoneal tumor and tumor-like lesions, proposing a systemic approach based on clinical history and morphological appearance, namely distinguishing predominantly cystic from solid lesions, both solitary and multiple.

Peritoneal carcinomatosis (PC) indicates advanced stage cancer, which is generally associated with a poor outcome and a 6 to 12 months. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an option for treating patients with primary PC, such as mesothelioma, or secondary PC, such as colorectal cancer (CRC) or pseudomixoma. Until recently, such patients were deemed untreatable. Objective: The purpose of this study was to assess the results of CRS + HIPEC in patients with PC. Postoperative complications, mortality and survival rates were evaluated according to the diagnosis. Results: Fifty-six patients with PC, undergoing full CRS + HIPEC between October 2004 and January 2020, were enrolled. The mortality rate was 3.8% and the morbidity rate was 61.5%. Complications were significantly higher in proportion to the duration of surgery (p

BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is the best effective treatment for pseudomyxoma peritonei (PMP). In the last years, the advances in histopathology have stratified PMP lesions in different degrees of aggressivity suggesting the possibility of a tailored treatment. In a subset of patients with small volume peritoneal disease, laparoscopic CRS and HIPEC is feasible. The aim of this study is to analyze the results of laparoscopic CRS + HIPEC in a monocentric series of patients under patient-related experience measures (PREMs). METHODS All consecutive patients who underwent laparoscopic CRS-HIPEC with curative intent at Cancer Institute of Montpellier were retrieved from a prospectively maintained database and analyzed. Selection criteria for laparoscopic approach were low-grade PMP with pathological confirmation prior to CRS-HIPEC, age

Research question Can preoperative or perioperative intervention reduce the risk of recurrence of endometriosis caused by either incomplete excision or spillage and dissemination? Design A mouse model of endometriosis recurrence caused by spillage and dissemination was first established using 24 female Balb/c mice. The spillage and dissemination model was used to test the efficacy of preoperative use of ketorolac, perioperative use of aprepitant and combined use of propranolol and andrographolide in a prospective, randomized mouse experiment involving 75 mice. The efficacy of these preoperative and perioperative interventions in a mouse recurrence model caused by incomplete excision was also tested using 72 mice. In all experiments, the baseline body weight and hotplate latency of all mice were measured and recorded before the induction of endometriosis, before the primary surgery and before sacrifice. In addition, all lesions were excised, weighed and processed for quantification and immunohistochemistry analysis of E-cadherin, α-SMA, VEGF, ADRB2 and putative markers of recurrence PR-B, p-p65, as well as Masson trichrome staining. Results All interventions substantially and significantly suppressed the outgrowth of endometriotic lesions and reduced the risk of recurrence caused by either spillage and dissemination or incomplete excision (P = 0.0007 to 0.042). These interventions also significantly attenuated the generalized hyperalgesia, inhibited the staining of α-SMA, p-p65, VEGF and ADRB2 but increased staining of E-cadherin and PR-B, resulting in reduced fibrosis. Conclusion Given the excellent safety profiles of these drugs, these data strongly suggest that preoperative and perioperative intervention may potentially reduce the risk of endometriosis recurrence effectively.

A 72-year-old man was introduced continuous ambulatory peritoneal dialysis (CAPD) for chronic renal failure. Five months later, he was pointed out a massive right pleural effusion. Being diagnosed with pleuroperitoneal communication, he was referred to our department for surgery. Dialysis fluid and indocyanine green were injected through a peritoneal catheter for CAPD 30 minutes before surgery. A small fistula was detected by pressing the abdomen and using infrared thoracoscopy. The fistula was sutured and covered with polyglycolic acid sheet and fibrin glue. A day after surgery, CAPD was resumed. He was discharged on the post operative sixth day without any complications.

IntroductionThe development of peritoneal adhesions and the effects of different antiadhesion agents on such mechanisms are not fully understood. Temporary rises of the C-reactive protein (CRP) level have been reported after antiadhesion agent application. We present the changes of inflammation markers observed after use of a starch-based polysaccharide certified for adhesion prevention and hemostasis 4DF (4DryField®PH).MethodRetrospective comparative analysis of inflammation markers in 40 patients undergoing laparoscopic adhesiolysis with or without adhesion prophylaxis was conducted. Statistical comparisons were performed by means of paired or unpairedttests (for normally distributed continuous data), Wilcoxon matched pairs signed-rank tests or Mann–Whitney tests (for not-normally distributed continuous data), Mantel–Cox tests (for continuous data describing time intervals), and Fisher’s exact tests (for discrete data).ResultsThe maximum post-operative CRP level was significantly elevated in the 4DF group (87 vs. 29%;p ConclusionThe starch-based polysaccharide 4DF can be considered safe and does not induce inflammatory reactions of clinical significance. Further studies regarding 4DF degradation are recommended and, apart from macrophage migration, could also examine corresponding markers such as IL-6 and PCT.

BACKGROUND Mesothelin is a cell surface glycoprotein overexpressed in 28%-58% of colorectal cancer (CRC). We hypothesized that CRC mesothelin expression contributes to peritoneal spread and that it is selectively overexpressed in those with peritoneal metastasis versus distant metastasis. METHODS This case-controlled study involved mesothelin immunohistochemistry staining of tumor specimens from patients with metastatic CRC/appendiceal cancers between 2017 and 2019. Staining reactivity was graded from trace to 4+ (low ≤1+; high >1+). Staining patterns were characterized on global (focal/patchy/diffuse) and cellular (apical/cytoplasmic) levels. Immunostaining of normal mesothelial cells served as internal control. RESULTS Thirty-one patients were identified: 11 peritoneal (study) and 20 distant metastasis (control). The control group did not include appendiceal cancers. The study group had greater proportion of high staining reactivity (55% vs. 5%; odds ratio [OR] = 20.4, 95% confidence interval [CI] 1.96-211.8). The study group had more diffuse (36% vs. 0%; OR = 22.2, 95% CI 1.1-465.3) and cytoplasmic staining patterns (73% vs. 28%; OR = 6.9, 95% CI 1.3-37.2). CONCLUSION Mesothelin expression is higher in CRC/appendiceal cancers with peritoneal metastasis than those with distant metastasis. Immunohistochemistry staining patterns suggestive of propensity towards peritoneal metastasis include diffuse and cytoplasmic staining. Mesothelin may be a potential target for novel treatments of CRC/appendiceal carcinoma with peritoneal involvement.

Keratin granulomas in the peritoneum are a rare finding with multiple etiologies and can be especially challenging for both the pathologist and the surgeon when these lesions are grossly visible. We report a case of a unique frozen section diagnostic scenario of evaluation of keratin granulomas in the peritoneum of a 47-year-old woman in the setting of multiple potential culprits: endometrial endometrioid adenocarcinoma following fertility sparing treatment, and a concurrent dermoid cyst. We discuss the various etiologies of keratin granulomas in the peritoneum, mechanism of their formation, diagnostic significance, as well as implications of fertility sparing treatments. To the best of our knowledge, this is the only case of keratin granulomas in the peritoneum with multiple distinct potential pathologic culprits as well the only case following fertility sparing treatment.

Objective To study the localization of and quantify different immune cell populations in red, black, and white peritoneal endometriotic lesions and compare immune cell densities between lesions and the surrounding tissue. Design Cross-sectional study. Setting Teaching hospital, university research laboratory. Patient(s) Participants undergoing laparoscopic excision of endometriosis were recruited from gynecological operating theaters at Royal Prince Alfred Hospital, Sydney (n = 28). Intervention(s) Immunohistochemical staining for and quantification of dendritic cells (mature and immature), T cells (effector, cytotoxic, and regulatory), B cells, and macrophages in endometriotic peritoneal lesions and the surrounding tissue. Main Outcome Measure(s) Immune cell densities and aggregates were quantified. Result(s) Red and black lesions are significantly more likely to be surrounded by immune cell aggregates than white lesions (P=.036). In the tissue surrounding the peritoneal endometriotic lesions, there was a consistent pattern of greater and more variable density of immune cell populations for red lesions than black or white lesions and a range of significant positive correlations between densities of different immune populations (all P≤.004; not observed within the lesion stroma). Conclusion(s) There is a greater presence of immune cells in the tissue surrounding earlier/red and black lesions than older scarred white lesions, particularly in the form of immune cell aggregates, indicating an immunologic response in close proximity to the adjacent lesion. The relationship between densities of immune populations in the tissue surrounding the lesions suggests complementary recruitment and local interactions between cells. Categorizing immune cell populations in proximity to peritoneal endometriotic lesions may improve the understanding of lesion persistence and transition to older white appearances. Early (red) peritoneal endometriotic lesions are surrounded by a greater density of immune cells, including immune aggregates, than later (black or white) lesions. These immune cells may support lesion persistence.

Omental torsion is a rare cause of abdominal emergency. Due to its clinical presentation and according to its localisation it is seldom diagnosed preoperatively as it imitates other more common diagnoses leading to surgical revision quite precisely. In this case report the authors present omental torsion with partial omental necrotisation in the right upper quadrant, imitating acute cholecystitis. The condition was managed by laparoscopic resection with a good clinical course postoperatively.

BACKGROUND The retroperitoneal hematoma is a very rare entity in obstetrics. A type of obstetric hematoma that extends into the retroperitoneal space, this hematoma usually occurs after laceration of the uterine artery, after uterine rupture, or by extension of a vaginal hematoma. Although the hematoma usually manifests as intense abdominal pain, sometimes the clinical signs can go unnoticed. This is the main reason it is important to report the cases in which retroperitoneal hematomas occur. In addition to clinical suspicion, experience in management can also help improve maternal morbidity and mortality from this cause. CASE REPORT We present a series of 3 clinical cases in which retroperitoneal hematomas occurred after instrumental deliveries. The 3 clinical cases described took place before the COVID-19 pandemic. In the first 2 deliveries, a vacuum was used, while in the third delivery, spatulas were used. CONCLUSIONS Our findings showed that suspicion is essential in patients with symptoms of nonspecific pain, as well as in patients with anemia that causes hemodynamic instability in the immediate postpartum period. The use of early computed tomography angiography in hemodynamically stable patients is essential to reach a diagnosis and to determine if the patient can be treated by embolization of the bleeding vessel.

Ectopic ovary is a rare gynaecological condition that results in problems with menstruation and pregnancy and may develop into a malignant tumour. However, as the condition is often asymptomatic, diagnosis is difficult and frequently delayed. We report a case of a 42-year-old female who presented with a 10-day history of abdominal pain. The patient underwent surgery that confirmed the diagnosis of an ectopic ovary with an internal abscess. The findings of our study indicate that ectopic ovaries can present with an abscess. Ectopic ovaries should be included in the differential diagnosis of masses with internal abscesses.

Aim of the study: Postoperative peritoneal adhesions are a common cause of morbidity after surgery, resulting in multiple complications. Macrophage-mediated inflammation and myofibroblast differentiation after tissue injury play central roles in the pathogenesis and progression of adhesion formation. Calponin 2 is an actin cytoskeleton regulatory protein in endothelial cells, macrophages and fibroblasts that are key players in the development of fibrosis. Deletion of calponin 2 has been shown to attenuate inflammatory arthritis, atherosclerosis and fibrocalcification of the aortic valves. The present study investigated the effect of calponin 2 deletion on attenuating the formation of peritoneal adhesions in a mouse model for potential use as a new therapeutic target.Materials and methods: Sterile surgical procedures under general anesthesia were used on paired wild type (WT) and calponin 2 knockout (KO) mice to generate mild injury on the cecal and abdominal wall peritonea. Three and seven days post-operation, the mice were compared postmortem for the formation of peritoneal adhesions. Tissues at the adhesion sites were examined with histology and immunofluorescent studies for macrophage and myofibroblast activations.Results: Quantitative scoring demonstrated that calponin 2 KO mice developed significantly less postoperative peritoneal adhesions than that in WT mice. Calponin 2 deletion resulted in less infiltration of F4/80+ macrophages at the adhesion sites with less myofibroblast differentiation and collagen deposition than WT controls.Conclusions: The data show that deletion of calponin 2 effectively reduces postoperative peritoneal adhesion, presenting a novel molecular target for clinical prevention.

STUDY OBJECTIVE To assess the feasibility of a noncontact radio sensor as an objective measurement tool to study postoperative recovery from endometriosis surgery. DESIGN Prospective cohort pilot study. SETTING Center for minimally invasive gynecologic surgery at an academically affiliated community hospital in conjunction with in-home monitoring. PATIENTS Patients aged above 18 years who sleep independently and were scheduled to have laparoscopy for the diagnosis and treatment of suspected endometriosis. INTERVENTIONS A wireless, noncontact sensor, Emerald, was installed in the subjects' home and used to capture physiologic signals without body contact. The device captured objective data about the patients' movement and sleep in their home for 5 weeks before surgery and approximately 5 weeks postoperatively. The subjects were concurrently asked to complete a daily pain assessment using a numeric rating scale and a free text survey about their daily symptoms. MEASUREMENTS AND MAIN RESULTS Three women aged 23 years to 39 years and with mild to moderate endometriosis participated in the study. Emerald-derived sleep and wake times were contextualized and corroborated by select participant comments from retrospective surveys. In addition, self-reported pain levels and 1 sleep variable, sleep onset to deep sleep time, showed a significant (p

Peritoneal pseudocysts (PPs) in patients who are diagnosed with Crohn’s disease (CD), is a rarely diagnosed entity with unknown epidemiology, etiology and pathogenesis. We present the case of a 30-year old male with known CD who presented with an acute abdomen because of a PP. PPs are developed as a complication caused in patients, suffering from mainly thee conditions. Firstly, PPs appear in patients with continuous ambulatory peritoneal dialysis (CAPD), they are also developed in patients with peritoneal trauma and finally in CD patients. Our case belongs to these three reported cases in our literature review, since it refers to a CD patient that developed PPs. He underwent emergency laparotomy and excision of the cyst, with good postoperative results. A literature review of 22 publications show that PPs often represent a diagnostic and therapeutic problem as it has a variable presentation and there are no data on what the best treatment option is – surgical excision or aspiration.

Ventriculoperitoneal (VP) shunts are commonly used in neurosurgical procedures to treat hydrocephalus. Although shunt-associated abdominal complications are well documented, extrahepatic pseudocysts are a rare shunt complication in adult patients. Therefore, we herein report the case of a 54-year-old male patient who presented with a bulging mass around the previous surgical site at the right upper quadrant of the abdomen. He had a 4-year history of VP shunt surgery for posthemorrhagic hydrocephalus. A computed tomographic scan revealed a large extrahepatic pseudocsyt. Our case represented a rare entity of extrahepatic pseudocyst in adult patients underwent VP shunt surgery. The clinical presentation, diagnostic tools, and treatment methods were discussed.

Endometriosis is one of the most common gynecological diseases diagnosed in almost 70% of patients with chronic pelvic pain (CPP). However, a quarter of women with pelvic pain is diagnosed with external genital endometriosis (EGE) during laparoscopy. A special group is represented by patients with PP that did not stop after the removal of endometrial foci. The mechanisms of the pathogenesis of the formation of pain syndrome are not completely explored yet. According to several authors, a significant role in the pathogenesis of pelvic pain recurrence after surgical treatment of EGE is played by active neuroangiogenesis, both in ectopic and eutopic endometrium. The aim of the study was to expand the understanding of the pathogenesis of pelvic pain that did not stop (recurrence) after surgical treatment of external genital endometriosis.The study involved 2 stages. At the first stage (algological), data from BB, NRS and VRS algological questionnaires, which were completed by patients with recurrent PP after surgical treatment of EGE, were analyzed (The results of the study have shown that the basis of pathogenesis of pelvic pain recurrence in patients who did not receive medical therapy after surgical treatment of EGE is the activation of neuro-angiogenesis processes and reduction of apoptosis. The results show a statistically significant 1.6 times increasing expression of NGF in eutopic endometrium (57.9 ± 2.5 vs 35.3 ± 2.1% of patients with the silent form of the gene and its receptor NTRK1 1.8 times (2.78 ± 0.25 versus 1.56 ± 0.21.e. respectively).

The present study was to find a pathogenic evidence for dopamine agonist application in patients with endometriosis associated pain syndrome.The study involved 227 patients of reproductive age with histologically confirmed genital endometriosis (GE) of I-III degree according to ASRM classification. The control group included 12 women with no laparoscope detected gynecologic pathology. The levels of prolactin (PRL), peripheral blood (PB), and peritoneal fluid (PF) were evaluated by chemiluminescence immune assay. The pain syndrome was measured by McGill visual analogue scale. Statistica10 program (StatSoft, Inc., Tulsa, OK) was applied for obtained data processing.A correlation was established between GE rate and levels of PRL and PB (Rs = 0.28,PRL involvement in GE pathogenesis and more intense therapeutic impact on pain syndrome in case of combined administration of dopamine and standard hormone therapy prove cabergoline application in clinical practice.

Genital endometriosis (GE) is a widespread gynecological disease which requires its further pathogenesis investigation and search for new effective treatments. The known data of oxytocin receptor presence in endometrioid heterotopy smooth muscle cells give some grounds to assume oxytocin participation in the pathogenesis of endometriosis. The present study objective was to evaluate oxytocin level in peripheral blood (PB) in patients with endometriosis associated pain syndrome and to estimate the efficacy of oxytocin receptor inhibitors (IOXTR) administration based on animal endometriosis model.The basic group comprised 61 patients with endometriosis associated pain syndrome, while 21 patients formed the control group. VAS, MPQ, and BBS objective tests were applied for pain syndrome evaluation. Oxytocin level in PB was measured by immunoenzyme method. After confirmation of endometriosis experimental model formation in rats and further randomization, a daily IOXTR intra-abdominal injection was performed in a dose of 0.35 mg/kg/24 h in the basic group (Oxytocin level in PB was authentically higher in patients with GE compared to the control: 51.45 (35.54-62.76) pg/mL and 27.64 (23.23-34.12) pg/mL, respectively (The obtained results confirm the oxytocin role in the pathogenesis of endometrioid associated pain syndrome. The high efficacy of IOXTR administration based on animal model of surgically induced endometriosis allows viewing this method as a perspective therapy.

STUDY QUESTION Do menstrual cycle-dependent changes occur in the histological appearance of superficial peritoneal endometriotic lesions, and are they equivalent to those observed in the eutopic endometrium? SUMMARY ANSWER Only a small subset of superficial peritoneal endometriotic lesions exhibits some histological features in phase with menstrual cycle-related changes observed in eutopic endometrium. WHAT IS KNOWN ALREADY Endometriotic lesions are frequently described as implants that follow menstrual cycle-related changes in morphology, as per the eutopic endometrium. This concept has been widely accepted despite the lack of conclusive published evidence. STUDY DESIGN, SIZE, DURATION This was a retrospective cohort study of 42 patients, from across the menstrual cycle, with surgically and histologically confirmed endometriosis. Patients were a subset selected from a larger endometriosis study being conducted at the Royal Women’s Hospital, Melbourne since 2012. PARTICIPANTS/MATERIALS, SETTING, METHODS Histological features of epithelium, stroma and gland morphology were examined in haematoxylin and eosin stained sections of superficial peritoneal endometriotic lesions and matched eutopic endometrium (menstrual: n = 4, proliferative: n = 11, secretory: n = 17, hormone-treated: n = 10). At least two biopsies (average = 4, range = 2–8 biopsies) and a matched endometrial sample were analysed for each patient and results were presented per endometriotic gland profile (n = 1051). Data were analysed using mixed effects logistic regression to account for multiple patients and multiple endometriotic biopsies, each with multiple endometriotic gland profiles. This model also enabled analysis of endometriotic lesions versus eutopic endometrium. MAIN RESULTS AND THE ROLE OF CHANCE There was considerable inter- and intra-patient variability in the morphology of superficial peritoneal endometriotic lesions. Menstrual cycle-associated changes were only observed for some features in a subset of endometriotic gland profiles. The proportion of endometriotic gland profiles with epithelial mitoses significantly increased in the proliferative phase (18% of gland profiles) relative to the menstrual phase (0% of endometriotic gland profiles) (odds ratios (OR) 9.30; 95% confidence intervals (CI) = 3.71–23.32; P 0.05). LARGE SCALE DATA Not applicable. LIMITATIONS, REASONS FOR CAUTION This study focused on features observed in sections of superficial peritoneal lesions and these may differ from features of deep infiltrating endometriosis or ovarian endometriomas. Cycle phases were limited to menstrual, proliferative and secretory phases to allow appropriate statistical modelling. WIDER IMPLICATIONS OF THE FINDINGS This study highlights heterogeneity in the histological characteristics of superficial peritoneal lesions. It challenges the assumption that lesion morphology consistently reflects menstrual cycle-associated changes. STUDY FUNDING/COMPETING INTEREST(S) Research reported in this publication was supported in part by National Health and Medical Research Council (NHMRC) project grants GNT1012245, GNT1105321 and GNT1026033 (P.A.W.R., J.E.G. and S.J.H.-C.). There are no competing interests.

Adhesions are permanent fibrovascular bands between peritoneal surfaces, which develop following virtually all body cavity surgeries. The susceptibility to develop, and the severity, of adhesions following intra-abdominal surgery varies within and between individuals, suggesting that heritable factors influence adhesion development. In this manuscript, we discuss the pathophysiology of adhesion development from the perspective of genetic susceptibility. We restrict our discussion to genes and single-nucleotide polymorphisms (SNPs) that are specifically involved in, or that cause modification of, the adhesion development process. We performed a literature search using the PubMed database for all relevant English language articles up to March 2020 (n = 186). We identified and carefully reviewed all relevant articles addressing genetic mutations or single-nucleotide polymorphisms (SNPs) that impact the risk for adhesion development. We also reviewed references from these articles for additional information. We found several reported SNPs, genetic mutations, and upregulation of messenger RNAs that directly or indirectly increase the propensity for postoperative adhesion development, namely in genes for transforming growth factor beta, vascular endothelial growth factor, interferon-gamma, matrix metalloproteinase, plasminogen activator inhibitor-1, and the interleukins. An understanding of genetic variants could provide insight into the pathophysiology of adhesion development. The information presented in this review contributes to a greater understanding of adhesion development at the genetic level and may allow modification of these genetic risks, which may subsequently guide management in preventing and treating this challenging complication of abdominal surgery. In particular, the information could help identify patients at greater risk for adhesion development, which would make them candidates for anti-adhesion prophylaxis. Currently, agents to reduce postoperative adhesion development exist, and in the future, development of agents, which specifically target individual genetic profile, would be more specific in preventing intraperitoneal adhesion development.

Endometriosis is a relatively common condition in which endometrial tissue is established in locations outside the uterus where, like the eutopic endometrium, it responds to hormonal stimuli and develops internal bleeding, inflammation, and fibrosis. These changes are associated with chronic and often debilitating cyclic pain and infertility. The pathogenesis of endometriosis is multifactorial, and several theories have been proposed to explain it. These include retrograde menstruation, celomic metaplasia, embryologic rests, and lymphovascular spread. Hormones, immunologic status, and genetic factors may also play a role. In most patients, the disease involves pelvic organs, but rarely it may also extend to a large variety of distant locations in the body. Patients with ovarian endometriosis are at higher risk for developing ovarian carcinomas including endometrioid and clear cell carcinomas. Some of these carcinomas may arise in a background of structural and/or nuclear atypia within the endometriotic foci. There is no known cure for endometriosis and treatment mostly consists of managing chronic pain or infertility.

Adenomyosis and endometriosis are common gynecological disorders, but their pathophysiology is still under debate. The aim of this review is to discuss whether adenomyosis and endometriosis represent two different entities or different phenotypes of a single disease. We searched PubMed electronic databases published between January 2000 and April 2020. Endometriosis is classified into three phenotypes; superficial peritoneal disease (SUP), ovarian endometrioma (OMA) and deep infiltrating endometriosis (DIE) lesions. Adenomyosis presents several different subtypes, including intrinsic adenomyosis, extrinsic adenomyosis, adenomyosis externa and focal adenomyosis located in the outer myometrium (FAOM). Human uterus is embryologically composed of archimetra, originating from the Müllerian duct, and neometra, arising from the non-Müllerian duct, and adenomyosis and endometriosis are diseases of archimetra. The outer myometrial layer of the uterus is composed of highly differentiated smooth muscle cells (SMCs), while the inner myometrial cells are immature. Inappropriate uterine contractions can cause retrograde menstruation and chronic inflammation in the pelvic cavity, then influencing the development of pelvic endometriosis. Furthermore, hyperperistalsis results in physiological and pathological changes to the endometrial-myometrial junctional barrier, allowing invagination of the normal endometrial tissue into the inner myometrial layer. This can trigger the development of intrinsic adenomyosis. There are insufficient data available to draw conclusions, but extrinsic adenomyosis may result from pelvic endometriosis and FAOM from rectal and bladder DIE/adenomyosis externa. In conclusions, this paper contributes to the debate in the possibility that adenomyosis and endometriosis represent different phenotypes of a single disease.

This study aimed to evaluate the presence of superficial peritoneal endometriosis (SUP) in women referred to emergency surgery for right iliac fossa (RIF) pain and undergoing an appendectomy, considering which factors may be useful to suspect and identify endometriosis.An observational case-control study was conducted on a group (n = 149) of fertile age women. After surgery, Group A was selected upon the diagnosis of endometriosis (n = 34); Group B (n = 115) represented the controls. Demographics, comorbidities and clinical findings were registered and analysed.Appendicitis of various grades of severity was diagnosed in all patients, but SUP was also identified in 23%, of which 14.7% also presented with endometriosis of the appendix. Women in Group A reported chronic pelvic pain, dysmenorrhoea, dyspareunia and oral contraceptive use more frequently. At multivariate analysis, factors associated with endometriosis were: age40 years, autoimmune disorders, multiple allergies, abdominal chronic pain, associated gynaecological pain symptoms, Alvarado score ≤6, and inconclusive ultrasound findings.The incidental finding of SUP in fertile age women presenting with an acute RIF pain and undergoing emergency surgery is a relevant observation. Clinical history and symptoms should guide surgeons in performing a correct diagnosis and in referring the patient to the gynaecology specialist.

OBJECTIVE. This article reviews the embryologic development, relevant anatomy, and imaging features, on CT, of pathologic processes involving the lesser sac and foramen of Winslow. CONCLUSION. The lesser peritoneal sac is an intricate anatomic region involved in many disease processes. It is a significant conduit for the spread of disease within the peritoneal cavity. The spectrum of pathologic processes pertaining to the lesser sac can be classified on the basis of the type of involvement, such as a fluid collection (e.g., transudate, exudate, bile, and blood), a mass (e.g., neoplastic or nonneoplastic conditions and lymphadenopathy), or an internal hernia into the lesser sac.

The perisplenic region is a complex anatomical area involving multiple peritoneal and subperitoneal structures, which influence the presentation and behavior of various pathologic processes. This review is a comprehensive resource for perisplenic anatomy and pathology with associated clinical presentations and imaging findings. Understanding the pathophysiologic intricacies of the perisplenic region assists the radiologist in building a helpful differential diagnosis and recognizing predictable disease patterns.

Mesenteric diseases are broadly separated into 2 groups: non-neoplastic and neoplastic. Common non-neoplastic mesenteric diseases include those involving the mesenteric vasculature and those of inflammatory processes. Mesenteric inflammatory processes can mimic a neoplastic process. Neoplastic diseases of the mesentery are rare. Generally, the morphology, behavior and diagnostic criteria for mesenteric tumors are similar to their soft tissue or organ-specific counterparts. Their recognition can be challenging because they sometimes are overlooked in differential diagnoses.

ContextWhile fibrosis in endometriosis has recently loomed prominently, the sources of myofibroblasts, the principal effector cell in fibrotic diseases, remain largely obscure. Mesothelial cells (MCs) can be converted into myofibroblasts through mesothelial-mesenchymal transition (MMT) in many fibrotic diseases and adhesion.ObjectiveTo evaluate whether MCs contribute to the progression and fibrogenesis in endometriosis through MMT.Setting, Design, Patients, Intervention, And Main Outcome MeasuresDual immunofluorescence staining and immunohistochemistry using antibodies against calretinin, Wilms’ tumor-1 (WT-1), and α-smooth muscle actin (α-SMA) were performed on lesion samples from 30 patients each with ovarian endometrioma (OE) and deep endometriosis (DE), and 30 normal endometrial (NE) tissue samples. Human pleural and peritoneal MCs were co-cultured with activated platelets or control medium with and without neutralization of transforming growth factor β1 (TGF-β1) and/or platelet-derived growth factor receptor (PDGFR) and their morphology, proliferation, and expression levels of genes and proteins known to be involved in MMT were evaluated, along with their migratory and invasive propensity, contractility, and collagen production.ResultsThe number of calretinin/WT-1 and α-SMA dual-positive fibroblasts in OE/DE lesions was significantly higher than NE samples. The extent of lesional fibrosis correlated positively with the lesional α-SMA staining levels. Human MCs co-cultured with activated platelets acquire a morphology suggestive of MMT, concomitant with increased proliferation, loss of calretinin expression, and marked increase in expression of mesenchymal markers. These changes coincided with functional differentiation as reflected by increased migratory and invasive capacity, contractility, and collagen production. Neutralization of TGF-β1 and PDGFR signaling abolished platelet-induced MMT in MCs.ConclusionsMCs contribute to lesional progression and fibrosis through platelet-induced MMT.

Background The clinical and economical value of routine submission of hernia sacs for pathological examination and scheduled clinic follow-ups after inguinal hernia and hydrocele repair has been questioned. Herein, we assessed the institutional variability in these routine practices. Methods We retrospectively reviewed patients who underwent unilateral or bilateral inguinal hernia and/or hydrocele repair, open or laparoscopically, at our institution from 2015 to 2018. Results 1181 patients were included (1074 inguinal hernias and 157 hydroceles). Of 531 specimens obtained from 446 (38%) patients, 515 (97%) were normal. 16 (3%) abnormal pathological findings included 7 with mesothelial hyperplasia, 5 with nonfunctional genital ductal remnants, 3 with ectopic adrenal cortical tissues, and 1 epidydimal structure which was not recognized at the time of surgery. 418 (35%) patients had scheduled clinic follow-ups 65 (IQR 46–94) days postoperatively. 44 (4%) patients with unexpected postoperative Emergency Department visits within 30 days of surgery were identified. Only one patient required inpatient treatment, and the rest did not require intervention or admission. The total direct cost of analyzing specimens during the study period was $30,798 CAD ($10,266/year). The average cost to detect a potentially significant finding was $1924.88/specimen and $2053.20/patient. Conclusions Routine pathological examination of hernia sacs and scheduled clinic follow-ups were associated with significant costs and predominantly nonsignificant findings. They should therefore be reserved for patients with a high clinical suspicion of injuries/abnormalities or risk factors for potential complications. Level of Evidence This is a level III evidence study.

BACKGROUND: We sought to determine whether laparoscopic hyperthermic intraperitoneal chemoperfusion (LS-HIPEC) improves overall survival (OS) in patients with gastric and gastroesophageal adenocarcinoma and low-volume peritoneal metastasis compared with standard of care treatment. METHODS: We reviewed data from a prospectively maintained database of patients with gastric and gastroesophageal adenocarcinoma to identify patients with radiologically occult carcinomatosis or positive peritoneal cytology, no evidence of distant metastasis, and without disease progression during initial chemotherapy or observation. Univariate and multivariable analyses were performed to evaluate the impact of LS-HIPEC on OS. RESULTS: We identified 25 patients who underwent LS-HIPEC and 27 treated with a standard of care approach due to patient (33.3%) or provider (51.9%) preference or financial limitations/lack of insurance coverage (14.8%). Resection was ultimately performed in 28% of LS-HIPEC patients and no standard care patients. At a median follow-up of 18.9 months, median OS was 24.7 (IQR 20.8-34.2) months in LS-HIPEC patients and 21.3 (IQR 12.3-23.1) months in standard care patients (p=0.08). Three-year OS in the LS-HIPEC group was 19.1%, compared with 9.6% (p=0.08). Patients who underwent resection had a median OS of 25.3 (IQR 22.6-47.1) months compared with 21.3 months in standard care patients (p=0.05). CONCLUSION: Neoadjuvant LS-HIPEC for the treatment of low-volume peritoneal disease in gastric and gastroesophageal cancer patients did not significantly improve OS compared with standard care. Multi-institutional studies are necessary to further elucidate the benefit of LS-HIPEC for this patient population.

The term intraperitoneal focal fat infarction (IFFI) includes various self-limiting clinical conditions that are caused by focal fatty tissue necrosis. Most of the cases of IFFI concern torsion or infarction of the greater omentum or the epiploic appendages. However, although rarely, perigastric ligaments can also undergo torsion also leading to fat infarction. IFFI clinically may mimic other pathologies, such as acute appendicitis or diverticulitis, making their clinical diagnosis a challenge. Ultrasound (US) and computed tomography (CT) have a high sensitivity and specificity for the diagnosis of IFFI excluding other pathologies, and in most cases, the clinical evolution is spontaneously favorable, thus helping to reduce the need for unnecessary surgical intervention. We review cases with IFFI in order to identify specific involvement patterns. Cases of epiploic appendages reported to an acute, subacute, and more chronic phase in order to present the self-limiting nature of this entity and the resultant absorption. We also present cases with falciform ligament infarction, as well as primary ("whirl sign" on CT due to greater omentum torsion) and secondary omental infarctions. The aim of this pictorial review is not only to extensively explore the imaging findings of IFFI but to also describe the clinical presentation and pathophysiology of the prementioned conditions.

Study Objective To describe the hospital-associated cost of endometriosis in Canada from April 2008 to March 2013. Design Population-based descriptive study. Setting Canada, with the exception of the province of Quebec. Patients All women aged 15 to 59 years discharged with endometriosis between April 2008 and March 2013. Interventions None. Measurements and Main Results Over 5 years, 47 021 women were admitted for endometriosis, resulting in a total hospital cost of Canadian dollars (CaD) $152.21 million (US dollars [US $] 147.79 million) and per-case cost of CaD $3237 (US $3143). Uterine endometriosis accounted for 28.29% of cases, ovarian endometriosis 27.44%, and other endometriosis 44.27%. Cost for uterine endometriosis was the highest at CaD $4137 (US $4017) per case, followed by ovarian endometriosis (CaD $3506; US $3404) and other endometriosis (CaD $2495; US $2422). The highest number of cases were in the groups aged 35 to 39 years (20.77%) and 40 to 44 years (20.44%). Hysterectomy accounted for 29.57% of surgical procedures. Encounters with hysterectomy were the costliest at CaD $5062 (US $4915) per case, followed by the ones with other surgical procedures at CaD $2477 (US $2405) per case, and admissions with no surgical procedure at CaD $2164 (US $2101) per case. Conclusion The hospital cost associated with endometriosis was approximately CaD $30 million (US $29.56 million) per year, whereas uterine endometriosis, hysterectomy, and older age were found to have a higher average cost per case. Although this study focuses specifically on hospital admission and does not account for outpatient costs or indirect costs, it nonetheless highlights the economic burden of this debilitating disease on Canadian society during the study period.

Research question: What are the protein levels and localization of oestrogen receptors (including ERa, ERb and G protein-coupled oestrogen receptor [GPER]) and hypoxia-inducible factor-1alpha (HIF-1a) in normal control endometrium (COEM) and ectopic endometrium from abdominal wall endometriosis (AWE). Design: AWE (n = 20) were obtained during surgery; COEM (n = 40) were collected by curettage. All tissues were obtained during the proliferative or secretory phase. Formalin-fixed paraffin-embedded tissues were used for immunohistochemical study for oestrogen receptors and HIF-1a proteins. Result(s): The expression of oestrogen receptors and HIF-1a in AWE differed from that in the corresponding menstrual cycle phase of COEM. Compared with COEM, ERa and HIF-1a were decreased whereas ERb and GPER were increased in AWE. The greatest difference was in GPER, with increased protein expression in both the cytoplasm and nucleus of endometrial epithelial and stromal cells, as well as a distinct change in localization from cytoplasmic expression to nuclear and cytoplasmic expression, compared with COEM. Conclusions: Our data suggest that the expression changes of oestrogen receptors and HIF-1a, especially GPER, are associated with AWE, which may provide new clues to understanding the cause of endometriosis.

Although radiation-induced mesenteritis or peritonitis can potentially exacerbate the risk of bowel obstruction, there are no data in the literature on the incidence of intestinal obstruction related to peptide receptor radionuclide therapy. Methods: The records of all patients treated with 177Lu-DOTATATE at Moffitt Cancer Center between April 2018 and October 2019 were evaluated. The number of patients who developed bowel obstruction within 3 mo of a 177Lu-DOTATATE treatment was divided by the total number of patients with preexisting peritoneal or mesenteric disease. Management strategies and outcomes were evaluated. Results: Of a total of 159 patients treated, 81 had baseline mesenteric or peritoneal disease, among whom 5 (6%) experienced at least 1 episode of bowel obstruction within 3 mo of treatment. Two of the patients underwent surgical exploration during obstruction describing a “frozen abdomen.” All 5 responded at least temporarily to high-dose corticosteroid treatment and regained bowel function, but 2 patients eventually succumbed to progressive peritoneal disease. Conclusion: Peptide receptor radionuclide therapy can lead to bowel obstruction in patients with mesenteric or peritoneal disease, likely by inducing inflammation. Corticosteroids can potentially play a role in treatment and prophylaxis.

"Atypical endosalpingiosis" (AE) is a diagnostic term used variably among pathologists to denote peritoneal lesions exhibiting architectural changes and/or cytologic atypia intermediate between endosalpingiosis and primary peritoneal serous borderline tumor (SBT). AE is a contentious entity and is not recognized in the current World Health Organisation Classification. We report a series of 10 cases classified as AE, in attempt to further characterize this lesion. The patients ranged in age from 24 to 72 yr (mean, 39.7 yr) and the commonest presenting complaint was abdominal pain. Operative findings usually comprised small peritoneal nodules and/or fibrous adhesions, predominantly involving the pelvis. The lesions were either mesothelial or submesothelial in location and typically exhibited mixed tubular and papillary architecture, sometimes with minor components of solid, cribriform or single cell growth. Epithelial multilayering was present in all cases but usually involved

To determine if intraoperative outcomes for patients undergoing laparoscopic hysterectomy with endometriosis and an obliterated cul-de-sac are different than patients with endometriosis and no obliteration of the cul-de-sac.A retrospective cohort study.An academic tertiary care hospital.Patients undergoing total laparoscopic hysterectomy with endometriosis between 2012 and 2016.Total laparoscopic hysterectomy, laparoscopic modified radical hysterectomy, and other procedures as indicated.A total of 333 patients undergoing hysterectomy were found to have endometriosis at the time of surgery. Ninety-six (29%) patients were found to have stage IV endometriosis as defined by the American Society for Reproductive Medicine staging criteria. Of those, 55 (57%) had an obliterated cul-de-sac, and 41 (43%) did not. The remaining 237 (71%) patients had stage I, II, or III endometriosis. Fifty-one (93%) patients with an obliterated cul-de-sac required laparoscopic modified radical hysterectomy compared with 12 (29%) patients with stage IV endometriosis without obliteration and 60 (25%) patients with stages I through III endometriosis (p.0001). The median total surgical time in minutes differed among the 3 groups as follows: obliterated cul-de-sac = 159 minutes, stage IV endometriosis without obliteration = 108 minutes, and stages I through III endometriosis = 116 minutes (p.0001). Additional procedures at the time of hysterectomy were more frequently performed for patients with an obliterated cul-de-sac and included salpingectomy (p = .02), ureterolysis (p.0001), enterolysis (p.0001), cystoscopy (p = .0006), ureteral stenting (p.0001), proctoscopy (p.0001), oversewing of the bowel (p.0001), and anterior resection and anastomosis (p = .006).Patients with stage IV endometriosis and an obliterated cul-de-sac required laparoscopic modified radical hysterectomy and various other intraoperative procedures more than patients with stage IV endometriosis without obliteration and stages I through III. Patients with obliterated cul-de-sacs who are identified intraoperatively should be referred to minimally invasive gynecologic specialists because of the difficult nature of these procedures and extra training required to perform them safely with limited morbidity.

Endometriosis is a gynecological disease characterized by pain and infertility. The diagnosis is very often made during the infertility work-up, together with other reproductive diseases and uterine disorders. A retrospective cohort study was conducted on infertile women with clinical or ultrasound suspect of endometriosis, undergoing an ultrasound (US) evaluation by a team of expert sonographers (

Context NOTCH signaling is activated in endometriotic lesions, but the exact mechanisms remains unclear. IL-6, which is increased in the peritoneal fluid of women with endometriosis, induces NOTCH1 through E-proteins including E2A and HEB in cancer. Objective To study the role of E-proteins in inducing NOTCH1 expression under the regulation of IL-6 in endometriosis. Setting and Design The expression of E-proteins and NOTCH1 was first investigated in endometrium of women with endometriosis and the baboon model of endometriosis. Regulation of E-proteins and NOTCH1 expression was examined after IL-6 stimulation and siRNA mediated inhibition of E2A or/and HEB in human endometriotic epithelial cells (12Z) in vitro, and subsequently following IL-6 treatment in the mouse model of endometriosis in vivo. Results E2A, HEB, and NOTCH1 were significantly upregulated in glandular epithelium (GE) of ectopic endometrium compared to eutopic endometrium in both women and the baboon model. IL-6 treatment upregulated the expression of NOTCH1 together with E2A and HEB in 12Z cells. Small interfering RNA inhibition of E2A and HEB or HEB alone decreased NOTCH1 expression. Binding efficiency of both E2A and HEB was significantly higher at the binding sites on the human NOTCH1 promoter after IL-6 treatment. Finally, IL-6 treatment resulted in a significantly increased number of endometriotic lesions along with increased expression of E2A, HEB, and NOTCH1 in GE of the lesions compared with the vehicle group in an endometriosis mouse model. Conclusions IL-6 induced NOTCH1 expression is mediated by E-proteins in the ectopic GE cells, which may promote endometriotic lesion development.

A total of 55 red, peritoneal endometriotic lesions and matched eutopic endometrial specimens were obtained from 46 patients with endometriosis.By assessing individual endometriotic lesion expression, we discovered an inverse relationship between