DISSEMINATED PERITONEAL LEIOMYOMATOSIS - A RARE ENTITY, COMPLICATED BY LATE BLEEDING FROM THE ILEOCOLIC VEIN.

Leiomyomatosis peritonei or disseminated peritoneal leiomyomatosis (DPL) is an extremely rare condition affecting mainly women of childbearing age with estrogen hypersecretion. It is characterized by the presence of multiple histologically benign smooth muscle nodules on the peritoneal surface and subperitoneal tissue mimicking peritoneal carcinomatosis. There are no clear guidelines for the primary management and follow-up o these patients. Case report: We represent a 44-years-old woman admitted due to two retroperitoneal tumors diagnosed on routine ultrasound screening. There was a past history of hysterectomy for uterine leiomyoma. The blood assay was normal. MRI revealed two well-circumcised tumors with a size of 15 cm and 6 cm, respectively, with a characteristic of leiomyoma. The tumors were removed completely. Macroscopically, they appeared as well-circumscribed masses with grey to white color, a rubbery texture, and a whorled cut surface. On the first postoperative day, due to a sudden drop of hemoglobin from 127 g/L to 6.8 g/L and clinical signs of acute intra-abdominal bleeding, the patient was reoperated. The site of bleeding was from the ileocolic vein located at the lower pole of the tumor. It was successfully controlled by ligation. The patient had an uneventful recovery. After five years she is free of recurrence. DPL is a rare disease, sometimes mimicking peritoneal carcinomatosis. The preoperative diagnosis should be suspected in women of childbearing age with estrogen hypersecretion and concurrent uterine leiomyomas. The management depends on the patient's age, reproductive plans, multiplicity, and symptomatology of DPL. Single tumors are best treated by surgery with synchronous hysterectomy or myomectomy in case of uterine myomatosis. In the case of symptomatic multiple DPL and fulfilled reproductive plan, bilateral salpingo-oophorectomy or treatment with Gonadotropin-releasing hormone analogs is indicated. In asymptomatic multiple DPL, the removal of all nodules is not mandatory because of the benign indolent course. The long-term prognosis of DPL is excellent.

Ileus caused by small bowel, ileocaecal and rectal endometriosis misdiagnosed as Crohn's disease and managed by synchronous ileocaecal and rectal resection.

The reported incidence of intestinal endometriosis varies between 22% and 37%, with bowel obstruction in only 2.3% of cases, but few series report acute obstruction. We report a rare case of acute bowel obstruction due to multiple bilateral deep intestinal endometriosis lesions localised in the ileum, ileocaecal valve and upper rectum, requiring synchronous resection in an emergency setting. A 42-year-old woman was referred to our clinic with a diagnosis of obstructing Crohn's disease based on abdominal computed tomography with oral contrast showing a thickened terminal ileum with stenosis, compression of the caecum and proximally dilated small bowel loops. Simultaneous ileocaecal resection and segmental resection of the upper rectum with handsewn end-to-end anastomosis between the sigmoid colon and rectum was performed. Owing to the advanced bowel obstruction and significant weight loss, a double barrelled ileoascendostomy was created. The patient had an uneventful recovery. Histological examination revealed transmural endometriosis with involvement of the pericolic fat in both specimens. Although intestinal endometriosis causing acute bowel obstruction is rare, it should be included among the differential diagnoses in young women with recurrent abdominal pain, intermittent diarrhoea and constipation without a family history for inflammatory bowel disease or cancer. Bleeding synchronous with menstruation is not typical for intestinal endometriosis. Right-sided intestinal endometriosis more frequently causes acute bowel obstruction, in most cases due to intussusception.

Liver transplantations in Bulgaria--initial experience.

The filed of liver transplantation (LT) continues to evolve and is highly effective therapy for many patients with acute and chronic liver failure resulting from a variety of causes. Improvement of perioperative care, surgical technique and immunosuppression in recent years has led to its transformation into a safe and routine procedure with steadily improving results. The aim of this paper is to present the initial experience of the transplant team at Military Medical Academy - Sofia, Bulgaria. For the period of April 2007 - August 2014 the team performed 38 liver transplants in 37 patients (one retransplantation). Patients were followed up prospectively and retrospectively. In 36 (95%) patients a graft from a cadaveric donor was used and in two cases--a right liver grafts from live donor. The mean MELD score of the transplanted patients was 17 (9-40). The preferred surgical technique was "piggyback" with preservation of inferior vena cava in 33 (86%) of the cases and classical technique in 3 (8%) patients. The overall complication rate was 48%. Early mortality rate was 13% (5 patients). The overall 1- and 5-year survival is 81% and 77% respectivelly. The setting of a new LT program is a complex process which requires the effort and effective colaboration of a wide range of speciacialists (hepatologists, surgeons, anesthesiologists, psychologists, therapists, coordinators, etc.) and institutions. The good results are function of a proper selection of the donors and the recipients. Living donation is an alternative in the shortage of cadaveric donors.