Spontaneous Uterine Perforation due to Pyometra Presenting as Acute Abdomen

Spontaneous perforation of the uterus is rare, its incidence being about 0.01% − 0.05%. We report a rare case of diffuse peritonitis caused by spontaneously perforated pyometra. A 63-year-old woman with severe abdominal pain was admitted to our hospital. Laparotomy was performed because of the suspicion of gastrointestinal perforation with generalized peritonitis. At laparotomy, about 900 mL of pus was found in the peritoneal cavity. There were no abnormal findings in the alimentary tract, liver, or gallbladder. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathological investigation of the surgical specimen revealed endometritis and myometritis of the uterus; but there was no evidence of malignancy, and the cervical canal was patent. Although spontaneously perforated pyometra is rare, a perforated pyometra should therefore also be considered when elderly women present with acute abdominal pain

Spontaneous Endometriosis of the Abdominal Wall

Abdominal wall endometriosis, the commonest type of extra-pelvic endometriosis, may rarely develop spontaneously in the absence of prior surgical scar. We aim to report 3 cases with this unique characteristic, two of them with a diagnosis of unusual development of umbilical endometriosis and one with inguinal endometriosis, from the perspective of a general surgeon. Because of the potential pitfalls in its diagnosis, endometriosis should be emphasized in the differential diagnosis of abdominal wall masses

Torsion of the Wandering Spleen

Wandering spleen, defined as a spleen without its usual peritoneal attachments, is a rare entity. We report a 34-year-old woman with acute abdomen due to torsion of the long vascular pedicle of a wandering spleen, displaced in the abdominal cavity, and infarction of the spleen. Wandering spleen was diagnosed by ultrasound and computed tomography (CT) scan, and was managed by splenectomy in this patient. Wandering spleen usually occurs in 20 to 40 years old women. The most common presentation is acute abdominal pain, although signs and symptoms vary widely. Due to the risk of splenic infarction, rapid and accurate diagnosis is essential. A confirmatory diagnosis of a wandering spleen depends heavily upon imaging studies such as abdominal ultrasound, abdominal and pelvic CT scanning, nuclear scintigraphy or a liver-spleen scan. Treatment options include splenopexy or splenectomy

Coronary Artery Bypass Grafting Combined with Total Occlusion of Internal Carotid Artery

Background: The presence of significant carotid stenosis in coronary artery bypass grafting (CABG) patients increases the risk of either transient ischemic attack or stroke. However, there is a dearth of data on the risk for patients with unilateral total occlusion of the carotid artery. We herein report our results of cardiac surgery in patients with unilateral total occlusion of the carotid artery. Methods: We examined 10,000 patients who underwent carotid artery duplex scanning before CABG or other cardiac procedures between January 2001 and September 2006 at Tehran Heart Center. The occlusions were detected via carotid Doppler screening and were confirmed through conventional or MR angiography. Among these patients, 15 (0.15%) patients had unilateral total occlusion of the internal carotid artery, and all of them underwent elective cardiac surgery. During cardiopulmonary bypass, the mean arterial pressure was maintained at above 60 mmHg with vasopressure drugs and increasing flow pump.Results: There were 4 patients with left and 11 patients with right carotid occlusions. Four patients had a history of cerebrovascular accident. The mean cross-clamp time (min) and perfusion time (min) was 50.7±17.3 and 94.2±26.7, respectively. The mean graft number was 4.1±0.9. One of these patients expired intraoperatively because of low cardiac output. In one (6.66%) patient, postoperative cerebrovascular accident occurred on the contralateral side of the totally occluded region. All the patients recovered uneventfully. Conclusion: Our results suggest that CABG can be performed in patients with unilateral total occlusion of the internal carotid artery without ipsilateral stroke using our strategies

Impact of Diabetes Mellitus on Peripheral Vascular Disease Concomitant with Coronary

Background: The aim of this study was to evaluate the impact of diabetes mellitus (DM) on peripheral vascular disease (PVD) in patients with coronary artery disease (CAD). Methods: A total of 13702 consecutive patients who underwent coronary artery bypass grafting (CABG) at Tehran Heart Center between January 2002 and March 2007 were included in this study. The demographic data, PVD, and outcome of these patients were reviewed. CABG patients before surgery were detected for PVD (stenosis ≥70% in the abdominal aorta; renal, carotid, and iliac arteries; or any other peripheral vascular system) with physical examination and past medical history. The suspected cases of PVD were, thereafter, confirmed via Doppler sonography or invasive angiography. Results: This study recruited 4344 diabetic patients (mean age 59.30±8.7 years) and 9358 non-diabetic patients (mean age 58.42±9.9 years). The diabetics were significantly older and had a higher incidence of PVD (2.7% vs. 1.8%), female gender, hypertension, renal failure, smoking, and dyslipidemia than the non-diabetics (P<0.05). There was no significant difference between the two groups with regard to family history and left main disease. Also, the mean ejection fraction (EF) was 48.85%±10.4 and 49.35%±10. In the patients with and without DM, respectively; and the difference was significant (P=0.008). The in-hospital mortality rate (mortality over a 30-day post-operative period) was 1.8% in the diabetics and 0.7% in the non-diabetics (P<0.001). In the multivariate analysis, PVD, left main disease, age, female gender, and EF were significant in the development of mortality amongst the diabetic patients with a respective odds ratio of 4.17, 5.54, 1.03, 2.86, and 0.95 (P≤0.050). In the multivariate logistic regression analysis, PVD was significantly higher in the diabetics than in those without DM (OR=1.283, 95% CI: 1.001- 1.644; P=0.049). In the diabetic patients, carotid (1.13% vs. 0.83%), subclavian (0.05% vs. 0.02%), femoral (0.18% vs. 0.09%), renal (0.62% vs. 0.25%), and tibialis (0.16% vs. 0.06%) arteries had a higher incidence of stenosis than those in the non-diabetics. Conclusion: We conclude that in diabetic patients with concomitant CAD, special attention must be directed towards the diagnosis of PVD using physical examination, Doppler sonography; and where needed, CT-angiography or invasive angiography. Also, in risk assessment, the presence of PVD should be strongly considered for CAD patients