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Primary ovarian carcinoid tumors (POCT) are well-differentiated neuroendocrine neoplasms and account for <0.1% of ovarian tumors. POCT usually arise in the context of mature cystic teratoma; however, pure primary ovarian carcinoids without teratomatous or mucinous elements are very rare. We present a case of a 54-year-old woman that underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy because of endometrial hyperplasia without atypia. The ovaries were macroscopically normal. Pathology report revealed a primary ovarian carcinoid with mixed trabecular and insular growth patterns. Immunohistochemical was positive for chromogranine A, synaptophysin, and CDX2. The Ki-67 index was <1%. To exclude a metastatic carcinoid to the ovary, a Ga-68 PET/CT was performed. This case highlights the microscopic and immunohistochemical characteristics of pure POCT and potential pitfalls in their differentiation from metastatic carcinoids. In addition, differential characteristics of primary and metastatic ovarian carcinoids are discussed.

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In the last decade, the widespread use of transvaginal ultrasound and the availability of highly specific serum assays of human chorionic gonadotropin (hCG) have become mainstays in the evaluation of early pregnancy. These tests have revolutionized the management of pregnancies of unknown location and markedly reduced the morbidity and mortality associated with the misdiagnosis of ectopic pregnancy. However, despite several advances, their misuse and misinterpretations are still common, leading to an increased use of healthcare resources, patient misinformation, and anxiety. This narrative review aims to succinctly summarize the ß-hCG dynamics in early gestation and provide general gynecologists a practical approach to patients with first-trimester symptomatic pregnancy.

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Resumen El manejo del tumor anexial en embarazadas sigue siendo un desafío. El objetivo del siguiente trabajo es realizar una revisión bibliográfica, en la que se abordarán las diferentes alternativas en cuanto a diagnóstico y manejo del tumor anexial en embarazadas, así como también indicaciones de abordaje quirúrgico y recomendaciones para una cirugía segura. Los tumores anexiales en embarazadas son poco frecuentes, y la mayoría son benignos y tipo funcionales. La ecografía ha sido fundamental para lograr diferenciar su carácter benigno o maligno. El manejo puede ser expectante o quirúrgico. El manejo quirúrgico se reserva para ciertas características de las lesiones anexiales. En cuanto a la vía operatoria, la literatura apoya la laparoscopia mostrando que existen múltiples beneficios al compararla con la laparotomía. Para el abordaje quirúrgico existen opciones en cuanto a la técnica, siendo estas anexectomía o quistectomía. Resulta fundamental tener consideraciones especiales en la técnica debido a los cambios fisiológicos de las embarazadas, como por ejemplo la altura uterina y el tamaño del tumor anexial. A modo de conclusión, el manejo de los tumores anexiales en el embarazo sigue siendo controversial y se extrapola principalmente basándose en la literatura de pacientes no gestantes u otros procedimientos quirúrgicos en embarazadas.

Abstract Nowadays the management of the adnexal tumors in pregnant women is still a challenge. The purpose of this article is to perform a bibliographic review and present the differential diagnosis, management, and surgical approaches for the women in this condition. Adnexal tumors in pregnant women are rare, most of them are benign corresponding to functional cysts. In order to differentiate benign from malignant tumors, Ultrasonography has been one of the most important imaging advances. The management can be either expectant or surgical. Surgical management is referred for tumors with certain specific characteristics. In relation to surgical management, the literature supports laparoscopy, showing greater benefits in comparison to laparotomy. There are different options for this kind of approach. Its mandatory to have special considerations in the technique due to the physiological changes in pregnant women, some examples are the uterine and the tumor size. The management of the adnexal tumors in pregnancy is still controversial, its based on studies of non-pregnant patients or other kinds of surgeries in pregnant women.

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STUDY OBJECTIVE: To demonstrate the application of the so-called reverse technique to approach deep infiltrating endometriosis nodules affecting the retrocervical area, the posterior vaginal fornix, and the anterior rectal wall. In Video 1, the authors describe the complete procedure in 10 steps in order to standardize it and facilitate the comprehension and the reproduction of such a procedure in a simple and safe way. DESIGN: A case report. SETTING: A private hospital in Curitiba, Paraná, Brazil. PATIENT: A 32-year-old woman was referred to our service complaining about cyclic dysmenorrhea, dyspareunia, chronic pelvic pain, and cyclic dyschezia. Transvaginal ultrasound with bowel preparation showed a 2.4-cm endometriotic nodule at the retrocervical area, uterosacral ligaments, posterior vaginal fornix, and anterior rectal wall, infiltrating up to the muscularis 10 cm far from the anal verge. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: Under general anesthesia, the patient was placed in the dorsal decubitus position with her arms alongside her body and her lower limbs in abduction. Pneumoperitoneum was achieved using a Veress needle placed at the umbilicus. Four trocars were placed according to the French technique as follows: a 10-mm trocar at the umbilicus for the 0 degree laparoscope; a 5-mm trocar at the right anterosuperior iliac spine; a 5-mm trocar in the midline between the umbilicus and the pubic symphysis, approximately 8 to 10 cm inferior to the umbilical trocar; and a 5-mm trocar at the left anterosuperior iliac spine. The entire pelvis was inspected for endometriotic lesions (step 1). The implants located at the ovarian fossae were completely removed (step 2). The ureters were identified bilaterally, and both pararectal fossae were dissected, preserving the hypogastric nerves (step 3). The lesion was separated from the retrocervical area, and the posterior vaginal fornix was resected (reverse technique), leaving the disease attached to the anterior surface of the rectum (step 4). The lesion was shaved off the anterior rectal wall using a harmonic scalpel (step 5). The anterior rectal wall was closed using X-shaped stitches of 3-0 polydioxanone suture in 2 layers (step 6). The specimen was extracted through the vagina (step 7). The posterior vaginal fornix was reattached to the retrocervical area using X-shaped sutures of 0 poliglecaprone 25 (step 8). A pneumatic test was performed to check the integrity of the suture (step 9). At the end of the procedure, hemostasis was controlled, and the abdominal cavity was irrigated using Lactate ringer solution (step10). CONCLUSION: The laparoscopic reverse technique is an alternative approach to face retrocervical or rectovaginal nodules infiltrating the anterior rectal wall. In this technique, the separation of the nodule from the rectal wall is performed at the end of the surgery and not at the beginning as performed within the traditional technique. This enables the surgeon to perform a more precise dissection of the endometriotic nodule from the rectal wall because of the increased mobility of the bowel. The wider range of movements serves as an ergonomic advantage for the subsequent dissection of the lesion from the rectum, allowing the surgeon to decide the best technique to apply for the treatment of the bowel disease (rectal shaving or discoid or segmental resection).

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BACKGROUND: Laparoscopy has become the standard of care in the surgical management of deep infiltrating endometriosis (DIE). However, it is a challenging procedure with a high complication rate. Despite the benefits of the minimally invasive approach, DIE resection is often performed by surgeons without adequate training, especially in developing countries like Chile. OBJECTIVE: To asses our experience in the diagnosis and laparoscopic management of DIE during seven years. METHODS: A retrospective cohort study of data including 137 patients with pathology-proven DIE. Surgical and fertility outcomes were evaluated. RESULTS: All procedures were performed laparoscopically without conversion. Dysmenorrhea and dyspareunia were the most common symptoms in 85.4% and 56.9%, respectively. Uterosacral ligaments were the most common DIE location. Endometrioma was present in 48.9% of cases. Median operative time was 140 minutes; however, it was longer in cases requiring bowel surgery (p < 0.0001). The complication rate was 10.9%. Median follow-up was 24.5 months. The pregnancy rate was 58.1% and 90% of patients reported significant symptom relief after surgery. CONCLUSION: Laparoscopic surgical management of DIE is effective and safe but it must be performed in tertiary centers with the availability of multidisciplinary teams.

INTRODUCCIÓN: La laparoscopía es actualmente el estándar en el manejo de la endometriosis profunda. Sin embargo, requiere de un entrenamiento específico e involucra la realización de procedimientos complejos y asociados a una alta tasa de complicaciones. Por lo anterior en Chile y Latinoamérica, la endometriosis profunda es frecuentemente manejada de manera inadecuada. OBJETIVO: Describir nuestra experiencia en el enfrentamiento clínico y manejo quirúrgico laparoscópico de la endometriosis profunda, durante los últimos siete años. MÉTODOS: Estudio de cohorte retrospectivo de 137 pacientes consecutivas operadas y con confirmación histológica de endometriosis profunda. Se recolectaron los datos demográficos, datos quirúrgicos, complicaciones, resultados reproductivos y seguimiento. RESULTADOS: Todas las cirugías fueron completadas por laparoscopía, sin conversión. La dismenorrea y la dispareunia fueron los síntomas más frecuentes en 85,4 y 56,9%, respectivamente. La localización más frecuente de endometriosis profunda fueron los ligamentos úterosacros, coexistiendo un endometrioma en 48,9% de los casos. La mediana de tiempo operatorio fue de 140 minutos, siendo significativamente más prolongado en casos con compromiso intestinal (p < 0,0001). Quince pacientes (10,9%) presentaron complicaciones. El seguimiento medio fue de 24,5 meses. La tasa de embarazo fue de 58,1% y 90% de las pacientes reportó una mejoría significativa de su sintomatología. CONCLUSIONES: El manejo laparoscópico de la endometriosis profunda es efectivo y seguro, pero debe reservarse a centros especializados y con disponibilidad de equipo multidisciplinario.

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Ovarian torsion after hysterectomy is a rare event. The diagnosis of ovarian torsion is challenging because symptoms are nonspecific. We present a case of ovarian torsion 2 years after laparoscopic hysterectomy (LH). Furthermore, we performed a literature review about ovarian torsion after hysterectomy. This case shows that, in cases of acute onset pelvic pain in patients with history of hysterectomy, the adnexal torsion must be kept in mind in the differential diagnosis, especially in those women who had undergone LH.

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Objective: To describe our experience with the multidisciplinary management of both thoracic/diaphragmatic endometriosis (TED), applying a broadened definition of the "Thoracic endometriosis syndrome (TES)" to define cases. Material and Methods: We present a retrospective series of consecutive patients affected by pathology-proven TED, treated at our institution, during a period of 7 years. Results: Five women were included. Two patients were referred due to catamenial chest/shoulder pain, one due to recurrent catamenial pneumothorax, and one due to new-onset diaphragmatic hernia. One patient had no thoracic symptoms, but diaphragmatic endometriosis was found during gynecologic laparoscopy for pelvic endometriosis. Endometriosis was histologically confirmed in all cases. After follow-up, all patients remain asymptomatic. Conclusion: Broadened TES criteria could increase the incidence of TED and determine better knowledge of this condition. Multidisciplinary, minimally invasive surgery is effective and safe, but should be reserved for tertiary referral centers.

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Introducción : La clasificación y gradación histológica de los tumores de glándulas salivales ha cambiado en los últimos años. La variedad y grado histológico son actualmente factores pronósticos independientes. Objetivo: Presentar los hallazgos histopatológicos en pacientes tratados en el Instituto Nacional del Cáncer de Santiago (INC) por tumores de glándulas salivales, en los últimos 12 años. Material y Métodos: Se revisaron retrospectivamente los registros clínicos de 168 pacientes atendidos en el INC ente enero 1992 y marzo 2004. Las biopsias fueron revisadas en la unidad de Anatomía Patológica de INC. Se registró edad, género, localización e histología. Resultados: La edad media del grupo (87 mujeres, 81 hombres) fue 54 años. Al diagnóstico, la edad media fue 51 años en pacientes con tumores benignos y 58 en aquellos con cáncer. El 75 por ciento (126 pacientes) correspondió a tumores paratídeos, 16 por ciento (26 pacientes) a tumores submandibulares, 8 por ciento (14 pacientes) a tumores de glándulas salivales menores y 1 por ciento (2 pacientes) a tumores sublinguales. Entre los tumores benignos, la variedad más frecuente fue el adenoma pleomorfo y la mayoría se localizó en la parótida. Entre los cánceres, en carcinoma adenoídeo-quístico fue la variedad predominante y se localizó mayoritariamente en la glándula submandibular y glándulas salivales menores. Conclusión: Aunque la patología benigna es mucho más frecuente, sobre todo en la glándula parótida, el riesgo de malignidad es aún elevado, sobre todo en pacientes mayores de sexo masculino.

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Splenic artery aneurysms are rare and occur predominantly in women. Most of them are asymptomatic until rupture. We report a previously healthy 73 year-old woman who presented with non specific symptoms: dyspepsia and constipation. Laboratory tests were normal. Subsequent examinations (ultrasound and CT) showed a large aneurysm of the splenic artery without any sign of rupture. Endovascular treatment remained successfully performed using coil embolization. During a 12-months follow-up period, the patient was asymptomatic and no evidences of complications or splenic infarction were observed on CT scans.

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