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.

An analysis of missed cases with surgical emergencies admitted in non-surgical departments. Case series and а review of the literature.

INTRODUCTION: The delayed diagnosis in emergency surgery can be associated with significant morbidity and mortality and often lead to litigations. The aim of the present work is to analyse the outcome in cases with non-trauma surgical emergencies wrongly admitted in non-surgical departments. METHODS: A retrospective trial in two independent University hospitals was conducted. The first group encompassed the patients worked-up in the Surgical unit of Emergency department (2014-2018). The second one included all cases visited Emergency department (2018). Only cases with acute abdomen and delayed diagnosis and operation were included. The analysis included the proportion of the delayed diagnosis, time between admission and operation, intraoperative diagnosis, complications and mortality rate. RESULTS: In the first group there were 30 194 visits in the surgical unit with 15 836 hospitalizations (52.4%). Twenty patients of the last (0.13%) were admitted in the Clinic of Infectious disease and subsequently operated. The mean delay between hospitalization and operation was 3 days (1-10). Seventeen patients (85%) were operated with mortality of 10%. In the second group, there were a total of 22 760 visits with 11 562 discharged cases. Of the last, 1.7% (n=192) were re-admitted in a surgical ward, 25 of which underwent urgent surgery (0.2%). CONCLUSIONS: The missed surgical cases represent only a small proportion of the patients in emergency department. The causes for wrong initial admissions in our series were misinterpretation of the symptoms, insufficient clinical examination and underuse of US and CT. The careful clinical assessment, point-of care US and CT may decrease the rate of the delayed diagnosis.

Endoluminal negative pressure therapy in colorectal anastomotic leaks.

AIM: The aim of the present work was to perform an up-to-date review of the literature on endoluminal negative pressure therapy for colorectal anastomotic leak. METHOD: An electronic search in PubMed and Google Scholar and a manual search without language restrictions were performed on 25 January 2019. Only original series reporting endoluminal negative pressure therapy in colorectal anastomotic leaks were included. The primary outcome was the success rate (complete closure of the abscess cavity). The secondary outcomes were the rates of complications and stoma closure. RESULTS: Nineteen series with a total of 295 cases were analysed. The median distance of the anastomosis from the anal verge and the size of the abscess were 5.65 cm (4.9-10) and 6.0 cm (5-8.1) respectively. In 84.5% (78%-91%) the stoma was created at the first intervention. Neoadjuvant therapy was performed in 48.6% (3%-60%). Median 7 sponges (2-34) were used with median negative pressure 150 mmHg (125-700) for a median of 31 days (14-127). The success rate was 85.4% (80%-91%) with ileostomy closure in 72.6%. Complications were observed in 19% (13%-25%): abscesses 11.5% and anastomotic stenosis 4.4%. Laparotomy was required in 15% of the complications. The stoma was the only significant predictor for the success of the therapy (0.007, SE 0.004, P = 0.040). CONCLUSIONS: The initial experience looks promising with an 85% success rate, which precludes risky re-resections with redo anastomosis or Hartmann's procedure. Despite the good initial results, definitive conclusions cannot be drawn because of the small sample size and the lack of high-quality comparative studies.

A rare case of life-threatening extra-peritoneal bleeding a.

INTRODUCTION: Although inguinal hernia repair is a routine procedure and frequently performed as one-day surgery, we should be particularly aware of the possible complications, which could be life-threatening if not recognized in due course. CASE REPORT: We report a case of life-threatening extra-peritoneal bleeding after open inguinal hernia repair requiring damage control surgery. DISCUSSION: Several vessels can be responsible for massive extraperitoneal bleeding - external iliac vessels, lower epigastric artery, crema steric vessels and corona mortis. Although damage control surgery was developed to treat the severe trauma, it can also be a life-saving maneuver in cases as the presented one. Hemodynamic instability with distended abdomen is a primary indication for laparotomy, but in some cases the contrast CT provides valuable information about the location and the size of hematoma and can guide the operative approach - midline laparotomy or revision of the wound as in our case. To the best of our knowledge, this is the first reported case of life-threatening retroperitoneal bleeding after open inguinal hernia repair. The present case is a good example for the application of damage control in pathology considered as one-day surgery. CONCLUSIONS: Although casuistic, the life-threatening bleeding after open hernia repair should be suspected. The prompt surgical response with damage control can be life-saving maneuver even in the routine hernia surgery. Detailed knowledge of the anatomy and carefull dissection are required to avoid this kind of complications.

Endoscopic enhanced-view totally extraperitoneal retromuscular approach for ventral hernia repair.

BACKGROUND: Primary or incisional ventral hernia repair is one of the most common surgical procedures, addressed to general surgeons. The enhanced view-totally extraperitoneal technique (eTEP) was first described by Deas for inguinal hernias, but lately it has been applied to ventral hernias by Belyansky et al. So far, results are promising and data about the procedure are rising. METHODS: Retrospective comparative analysis of 27 recruited eTEP procedures and 27 IPOM operations for the period between April 2017 and June 2018 at the department of Endoscopic surgery of Military Medical Academy, Sofia. Baseline characteristics, operative records and perioperative data are provided and compared for both groups. RESULTS: Fifty-four patients were included. There were no differences between age, sex, BMI, primary or incisional hernias, co-morbidity, active smoking, EHS-classification and immunosuppression through the patients in different groups. Mean defect area-eTEP is 71 cm2 with no statistical difference, compared to IPOM-76 cm2. Operative time in eTEP is significantly longer with mean time of 186 min and 90 min in IPOM patients. Mean length of stay did not differ between the groups, with 2.9 days after eTEP and 3.4 after IPOM. Median pain score from the intraoperative (the day of surgery) to the seventh postoperative day is lower in the eTEP group. No surgical site infections and/or mesh infections were present. There was one readmission in the IPOM group with ASBO, and it was managed conservatively. There were no reinterventions and perioperative mortality in the sample. CONCLUSION: We found out that the eTEP/eRS approach is feasible and safe. Our study shows comparable results of eTEP/eRS to the IPOM procedure with reduced video analogue scale pain score to the 7th postoperative day and increased operative time. The study contributes to the upcoming evidence in the field of new minimally invasive techniques for ventral hernia repair.

[OPEN LAPAROSCOPY--A MODIFIED HASSON TECHNIQUE].

The open technique was first described by Hasson in 1970. This technique consists of creating a small umbilical incision under direct visualization to enter the abdominal cavity followed by the introduction of a blunt trocar. Pneumoperitoneum is then rapidly created. Hasson proposed its potential benefits to be the avoidance of blind insertion of the Veress needle and bladed trocar, prevention of visceral and vascular injuries, preperitoneal insufflation and gas embolism, guaranteed pneumoperitoneum, and a more anatomical repair of the abdominal wall. Since that time, many surgeons have made some modifications to first Hasson technique. Here we described the way we do the open laparoscopy in our hospital and different positive and useful details we put to original Hasson version.

A modern combat trauma.

INTRODUCTION: The world remains plagued by wars and terrorist attacks, and improvised explosive devices (IED) are the main weapons of our current enemies, causing almost two-thirds of all combat injuries. We wished to analyse the pattern of blast trauma on the modern battlefield and to compare it with combat gunshot injuries. MATERIALS AND METHODS: Analysis of a consecutive series of combat trauma patients presenting to two Bulgarian combat surgical teams in Afghanistan over 11 months. Demographics, injury patterns and Injury Severity Scores (ISS) were compared between blast and gunshot-injured casualties using Fisher's Exact Test. RESULTS: The blast victims had significantly higher median ISS (20.54 vs 9.23) and higher proportion of ISS>16 (60% vs 33.92%, p=0.008) than gunshot cases. They also had more frequent involvement of three or more body regions (47.22% vs 3.58%, p<0.0001). A significantly higher frequency of head (27.27% vs 3.57%), facial (20% vs 0%) and extremities injuries (85.45% vs 42.86%) and burns (12.72% vs 0%) was noted among the victims of explosion (p<0.0001). Based on clinical examination and diagnostic imaging, primary blast injury was identified in 24/55 (43.6%), secondary blast injury in 37 blast cases (67.3%), tertiary in 15 (27.3%) and quaternary blast injury (all burns) in seven (12.72%). CONCLUSIONS: Our results corroborate the 'multidimensional' injury pattern of blast trauma. The complexity of the blast trauma demands a good knowledge and a special training of the military surgeons and hospital personnel before deployment.

Single centre experience with surgical treatment of hilar cholangiocarcinoma.

UNLABELLED: BACKGROUND /AIMS: Surgical resection is a radical treatment option for hilar cholangiocarcinomas. However it is still difficult to cure and patient prognosis is poor. An evaluation of the surgical options and results may elucidate effective treatments. METHODOLOGY: We retrospectively examined the demographic characteristics, surgical records and outcome in 64 patients with hilar cholangiocarcinoma undergoing surgical resections or palliative surgical procedures for the period of 2004-2012. RESULTS: The patients included 43 males and 17 females with a mean age of 61.4 ± 10.4 years (±SD, range 35-81 years). Forty four resections were done - R0-22 cases (34.4%), R1 - 10 (15.6 %) cases, R2 -12 cases (18.7%) and 20 palliative (31.3%) operations were performed. R0 - resection of common bile ducts with right hepatectomy with Sg 1 was done in 8 cases, resection of common hepatic duct with left hepatectomy with Sg 1 in 9 cases and resection of common hepatic duct in 5 cases. The total percentage of postoperative morbidity is 51.5 %. The types of complications are as follows: intra abdominal bleeding 31.25 %, temporary biliary leakage - 26.56 %, leakage of hepatico-jejunostomyâ7.81 %, biliary fistula 7.81%, liver insufficiency 17.18 %, pleural effusion 48.13 %, intraabdominal abscess 28.13 %, surgical site infection 48.3 %. The mean five-year overall survival for R0 - resection is 32%, for R1 - and R2 - resection is 12% and for the palliative operations - 0%. The mean overall survival for R0-resection is 37 months, for R1 - and R2 - resection is 19 months and for the palliative operations 7 months. CONCLUSIONS: Radically extended surgical resection for hilar cholangiocarcinoma is necessary to obtain improved patient survival.

[Pancreatic cancer--multidisciplinary approach and possibilities for surgical treatment].

Pancreatic cancer is one of the most serious and severe diseases and takes a significant part of malignant diseases in Bulgaria, during the last years. The fast progression of this disease requires complex treatment and is still a considerable challenge for the conservative and the surgical approaches. We present a series of 196 consecutive patients operated in our clinic for the period September 2003-February 2008. 106 radical pancreatic resections and 90 palliative procedures were performed. All of the patients were assessed before operation by multimodality team using standard protocols. The criteria for respectability are absence of distant metastasis as well as absence of data for infiltration of celiac trunk and superior mesenteric artery. In the presented series the percent of respectability is 54.1%. 35 Whipple procedures. 49--Traverso-Longmire (PPPD--resections), 15-distal pancreatectomies and 7 papillectomies were performed. In 28 cases the pancreatic resection was combined with vessel resection. 17 patients underwent extended resections. The average postoperative stay for the patients with radical operations is 16.1 days. 39 patients (36.8%) had complications. Six patients among the radically operated died (5.6%). The average survival rate for the patients with radical surgical interventions is 16.2 months. The surgical resection is the only method of choice for radical treatment of pancreatic cancer and periampular tumors. The indications for pancreato-duodenal resections have expended thanks to the development of the surgical technique and reanimation care during the last ten years. In order to achieve better results it's recommended that type of surgery to be concentrated in highly specialized centers.

[Contemporary aspects in the performance of pancreatic anastomosis after pancreatoduodenal resecions].

BACKGROUND: Historically, the pancreatic anastomosis has a significant impact on the high morbidity levels in pancreatoduodenal resections. This leads to parallel development of alternative techniques for reconstruction. The major methods are pancreato-jeuno and pancreato-gastroanastomosis. MATERIAL AND METHODS: We present 82 consecutive cases with pancreatoduodenal resections for the reason of pancreatic head malignancies. Pancreato-jeunal anastomosis is the preferred method and the evolution in the anastomosing technique of pancreatic rermnat is presented. RESULTS: Nine patients had pancreatic fistula (10.9%) and in six cases (7.3%) intra abdominal abscess was observed. CONCLUSIONS: Our experience as well as the analysis of different investigations confirmed the thesis that each center should choose one of the major techniques and develop it--clear tendency of decrease of the frequency of pancreatic fistulas with the growth of the experience, is observed.