be suspected when one is faced and tively treated appendiceal abaceas. Br J Stag 1936; 24: with local or generalized peritonitis. 399-401 increasing toxemia, cellulitis and crepi- When dealing with a gas gangrene 3. WYMAN AL: Endogenous gas gangrene complicating tus. Diagnostic help may come from infection one must distinguish among carcinoma of colon; report of case. Br Med J 1949; 1: radiologic and bacteriologic examina- clostridial, nonclostridial and mixed in- 266-267 4. KIMBALL HW, RAWSON AJ: Nontraumasic gas gan- tion. The situation is usually apparent fections, as the treatments differ. The grene. Va Med Mon 1952; 79: 269-271 when problems have developed after antibiotic commonly used against Cbs- 5. WARTHEN HJ: Gas gangrene; a review of 71 cases. Ann trauma or surgery. Early diagnosis is tridium organisms may not be of much Ssrg 1942; 115: 609-620 6. SILvER MD: Gas gangrene following perforation of the much more difficult, though, in con- value in other kinds of gas gangrene, alimentary canal; a report of four cases. Can Med Assoc cealed infections, when it may not be and hyperbaric oxygen has no effect in J 1961; 84: 1418-1421 7. SOMMERS HM: The indigenous microbiota of the possible to get material for bacteriologic infections with E. coil." Bacteriologic human host. In YOUMANS GP, PATERSON PY, SOM- examination without surgery. Crepita- examination is essential for accurate MERS HM: The Biologic and Clinical Basis of Infec- tion is not always present in the early diagnosis, and until the results of the Sbus Diseases, 2nd ed, Saunders, Philadelphia, 1980: 90-92 stages, and usually by the time it has cultures are known it is safer to use 8. GOUDIE JG, DUNCAN IBR: Cl. welchil and neutralizing become obvious the toxemia is profound. antibiotics effective against both cbs- substances for Cl. welchii, alpha-toxin in feces. J Pathol Radiologically one sees progressive ad- tridial and nonclostridial organisms. Bacteriol 1956; 72: 381-392 9. GOUDIE JG: The nature of a neutralizing substance for vance of the gas in the muscle bundles, Clostridium welchil, alpha-toxin in faeces. J Pathol visible as bubbles, pockets or streaks. It Bacteriol 1959; 78: 17-28 References 10. BESSMAN AN, WAGNER W: Nonclostridial gas gan- is best demonstrated in lateral views grene; report of 48 cases and review of the literature. with the suspected area uppermost. Per- JAMA 1975; 233: 958-963 foration of the bowel, however, may also 1. WEINTROB M, MESSELOFF CR: Gas gangrene in civil 11. HEDSTR.M SA: Differential diagnosis and treatment of practice. AmJMedSci 1927; 174: 801-819 gas-producing infections. Acta Chir Scand 1975; 141: give rise to intra- or extraperitoneal air 2. GORDON SB: Welchii infection complicating conserva- 582-589 Ovarian remnant syndrome DAVID MURAM, MD, FRCS[CJ PIERRE DROUIN, MD, FRCS[C] Usually an ovary can be removed with- Civic and Ottawa General hospitals in the retroperitoneal space. It was cov- out difficulty. However, when it is at- have been found to have clinically and ered by the posterior peritoneum and tached to other pelvic organs or the histologically confirmed ovarian rem- was adherent to the bladder, the left pelvic wall some of the cortex may nant syndrome. In this paper we outline ureter and the left pelvic wall. The cyst adhere to the peritoneal surfaces of the signs and symptoms that may sug- was dissected from its pelvic attach- those structures. The cortical tissue, gest this syndrome before surgical inter- ments and removed. A small part of the which has been separated from its major vention and describe our way of manag- lining of the cyst was left attached to the blood supply, may undergo necrosis, ing such patients. mesenteric vessels so that the blood cystic degeneration or neoplastic change, supply to the sigmoid colon would not be or it may remain functional, as experi- Case reports compromised. Histologic examination of ments with cats have demonstrated.' the cyst revealed remnants of ovarian The condition in which the detached Case 1 cortex and an endometriotic cyst. ovarian tissue remains functional is Two years later the patient had no called the ovarian remnant syndrome. A 42-year-old woman underwent a genitourinary symptoms, and a pelvic This syndrome should be considered in laparotomy for lower abdominal pain examination yielded no abnormalities. all patients presenting with genitouri- and an adnexal mass. A right ovarian nary symptoms or a pelvic mass follow- endometrioma was found and removed, Case 2 ing bilateral salpingo-oophorectomy, and microscopic examination confirmed with or without hysterectomy, particu- the clinical diagnosis of endometriosis. A 34-year-old woman underwent total larly in those with endometriosis or A year later she underwent a total abdominal hysterectomy and bilateral chronic pelvic inflammatory disease. abdominal hysterectomy and bilateral salpingo-oophorectomy for severe en- The ovarian remnant syndrome is salpingo-oophorectomy because of in- dometriosis. Hormone therapy was given considered rare; since 1962 only 22 cases creasing pain and dysfunctional uterine postoperatively but was stopped after 6 have been reported.'5 However, some bleeding. Postoperatively she had no months because the symptoms had dis- patients whose postoperative genitouri- menopausal symptoms and refused hor- appeared. The patient remained free of nary symptoms have been attributed to mone therapy. She remained well for 6 symptoms, including menopausal, for adhesions, scarring from endometriosis years, then presented with urinary fre- 51/2 years, until she noted abdominal or an inflammatory process may, in fact, quency and urgency. enlargement and urinary frequency and have ovarian remnant syndrome. Physical examination revealed a large urgency. Urologic investigation, includ- Recently three patients at the Ottawa multicystic mass fixed to the left pelvic ing cystoscopy, yielded no abnormalities, From the department of obstetrics and gynecology, wall, and an intravenous pyelogram but the urinary symptoms worsened, and University of Ottawa showed partial obstruction of the left her abdomen continued to enlarge over Reprint requests to: Dr. Pierre Drouin, Department ureter. At laparotomy a multiloculated the next 6 months. of obstetrics and gynecology, Ottawa General Hos- cyst 8 cm in diameter was found in the Physical examination revealed a large pital, 501 Smyth Rd., Ottawa, Ont. K1H 8L6 mesentery of the sigmoid colon, mainly tender cystic mass extending from the CMA JOURNAL/SEPTEMBER 1, 1982/VOL. 127 399 pelvis to the umbilicus, and intravenous The patient was admitted to hospital reveals a mass. Even though the mass is pyelography showed a large mass com- with an acute exacerbation of the ab- probably an endometriotic cyst or is due pressing both ureters. At operation a dominal pain and vaginal bleeding of 4 to cystic degeneration of the ovarian multiloculated cyst 20 cm in diameter weeks' duration. Physical examination remnant, malignant disease has to be containing chocolate-like material (Fig. revealed a tender cystic mass adjacent to ruled out. In Shemwell and Weed's 1) was found in the pelvis. It extended to the right wall of the uterus. At laparoto- study' adenocarcinoma was present in 1 the retroperitoneum and encroached my a cystic mass 4 to 5 cm in diameter of 10 patients with an ovarian remnant. upon the common iliac arteries and veins was found in the broad ligament com- Enlargement is more likely to be due to on both sides. The cyst was drained to pressing the right ureter. The mass was malignant disease after the menopause. facilitate dissection, and its lining was resected and a total abdominal hysterec- Constant or intermittent obstruction of removed except for a small portion at- tomy performed. Histologic examination the ureter requires surgery to relieve tached to the mesenteric artery. His- of the removed specimen revealed rem- both the obstruction and the pain.2'5 tologic examination revealed a corpus nants of the right ovarian cortex con- The ovarian remnant may be in- luteum and a large endometrioma. Six taining cystic follicles and a recent or- traperitoneal or retroperitoneal or both. days after the operation the patient ganizing hemorrhagic corpus luteum. If it is not evident in the intraperitoneal complained of severe menopausal symp- After the operation the patient com- space a careful search should be made of toms; she was therefore given medroxy- plained of hot flushes, fatigue and in- the retroperitoneal space. The remnant progesterone acetate, 150 mg intramus- somnia; she therefore received estrogen may be adherent to major blood vessels, cularly every 2 weeks to suppress the replacement therapy with Premarin, the ureters or the mesentery of the endometriosis and relieve the menopaus- 1.25 mg/d. Two years later the pain in bowel. Dissection and removal of the al symptoms. the pelvis had disappeared and a pelvic remnant may damage these vital struc- Eighteen months later she was symp- examination yielded no abnormalities. tures or compromise their blood supply; tom-free, and a pelvic examination in such instances small adherent por- yielded no abnormalities. Discussion tions may be left in situ. One should identify the ureters and major blood Case 3 Diagnosis vessels on both sides of the mass before dissection and choose the easiest method A 33-year-old women presented who The ovarian remnant syndrome of dissection. If the mass is benign, had undergone removal of a dermoid should be suspected in patients who have drainage of the fluid in the cyst will cyst during a cesarean section, removal had bilateral oophorectomy, especially if relieve the pressure, decrease the size of of a hemorrhagic cyst from the right the dissection was difficult or the planes the mass and facilitate the dissection. ovary, and left salpingo-oophorectomy of dissection were indistinct, as in en- However, if it is suspected to be malig- for bening serous cystadenoma. Shortly dometriosis or pelvic inflammatory dis- nant every effort should be made to before the present admission a right ease.