Persisting bleeding from the duodenal ulcer in patients with occlusion of the celiac trunk: a case report.

INTRODUCTION: Endoscopic measures have continued to be the primary procedures in the management of ulcer bleeding. Nevertheless, in cases of failed endoscopic hemostasis and re-bleedings, endovascular techniques have gradually gained increased acceptance as an alternative to surgery, allowing to avoid surgical intervention in some cases. <br/> Case report: A case of a 42-year-old patient presenting to the authors' institution with massive bleeding from the duodenal ulcer, sprang from a pathologically enlarged gastroduodenal artery is reported. This vascular anomaly was a consequence of occlusion of the coeliac trunk (Dunbar syndrome), which was shown on an angio-CT scan. In spite of several endoscopic and endovascular measures, as well as three operations, the bleeding persistently recurred (a total of 6 episodes) and the patient eventually died. The article presents details of operative and endovascular treatments. Contemporary trends in management in cases of failed endoscopic interventions and re-bleedings form peptic ulcers are shown in the discussion.

Surgical management and outcome of bile duct injuries following cholecystectomy: a single-center experience.

PURPOSE: Biliary injury is a severe complication of cholecystectomy. The Hepp-Couinaud reconstruction with the hepatic duct confluence and the left duct may offer best long-term outcome as long as the confluence remains intact (Bismuth I-III). Complex liver surgery is usually indicated in most proximal (Bismuth IV) injuries in non-cirrhotic patients. The aim of this study was to evaluate the surgical treatment and outcome of bile duct injuries managed in a referral hepatobiliary unit. METHODS: We retrospectively analyzed surgical management and outcome of biliary injuries following cholecystectomy in 35 patients (27 laparoscopic) referred to our center between June 2001 and December 2009. There was no liver cirrhosis diagnosed in any patient. High injuries (Bismuth III-IV) were found in 14 patients. Management after referral included the Hepp-Couinaud hepaticojejunostomy in 32 patients with Bismuth I-III injuries, which in four cases with biliary peritonitis was preceded by abdominal lavage and prolonged external biliary drainage. Liver transplantation was performed in two patients with Bismuth IV injuries. RESULTS: After median follow-up of 59 months (range, 6-102), 34 (97%) patients are alive and 32 (92%) remain in good general condition with normal liver function. One patient who had combined biliary and colonic injury died of sepsis before repair. Recurrent strictures following the Hepp-Couinaud repair developed in two (6%) patients with high injuries combined with right hepatic arterial injury. CONCLUSION: The Hepp-Couinaud hepaticojejunostomy offers durable results, even after previous interventions have failed. In case of diffuse biliary peritonitis, delayed biliary reconstruction following external biliary drainage may be the best option.

[Diagnostic difficulties in gastrocolic fistulas as a complication of surgical management of peptic ulcer: case report]. / Trudnosci w ustaleniu rozpoznania przetoki zoladkowo-okrezniczej powstalej w nastepstwie chirurgicznego leczenia choroby wrzodowej--opis przypadku.

A gastrointestinal fistula is a late complication of peptic ulcer disease and forms when gastric resection is inadequate or vagotomy is incomplete or not performed. Such cases are extremely rare and are occasionally reported in the literature. We present a patient with a gastrocolic fistula which developed 7 years after partial gastrectomy due to pyloric stenosis as a sequella of peptic ulcer. Nonspecific clinical symptoms and ambiguous radiographic findings delayed the diagnosis of gastrocolic fistula. The patient was operated; "en bloc" resection of the fistula with partial resection of the transverse colon and stomach supplemented with truncal vagotomy was done. The possible cause of recurrence of peptic ulcer in this patient was that vagotomy was not done during the first surgical intervention. Thus, the gastrocolic fistula became a late complication of the recurrence of peptic ulcer. Diagnostic difficulties in gastrocolic fistulas are presented and surgical management of this complication is discussed.

Arteriovenous fistula: a rare complication of nephrectomy in a child with Wilms tumour.

The case of a 13-year-old boy with a renal arteriovenous fistula in the left renal pedicle after nephrectomy is presented. The fistula was successfully managed by percutaneous transluminal embolization with coils sparing the patient the burden of surgery. Attention is drawn to the very rare incidence of this complication after nephrectomy in children with Wilms tumour.

Value of high resistance index - HRI calculated from Doppler spectrum of popliteal arteries in patients with systemic lupus erythematosus (SLE).

BACKGROUND: HRI is a new Doppler index calculated as a ratio between S -maximal systolic flow and D -maximal early diastolic reversed flow -HRI=D/S. The aim of the study is to evaluate the diagnostic significance of HRI calculated from the Doppler spectrum of popliteal arteries in patients with systemic lupus erythematosus (SLE) with and without secondary antiphospholipid syndrome (SAPS) compared with healthy controls. MATERIAL/METHODS: During 9-month period (May 2003 -January 2004), 93 patients (81 women and 12 men) with SLE (including 24 patients with SAPS) and 30 healthy controls (24 women and 6 men) underwent bilateral duplex Doppler examinations of lower limb arteries. The examinations were performed using HDI 3500 (ATL) with 5 -12 MHz linear transducer under standardized conditions: correct insonation angle and sample volume size, with the patient in a supine position, after 10 minutes rest. RESULTS: Mean HRI value obtained in the control group was 0.415 (range 0.305 -0.555; median 0.402). In the group of SLE patients without SAPS, mean HRI value was decreased to 0.320 (range 0 -0.584; median 0.334) and even lower -0.283 in SLE patients with SAPS (range 0.106 -0.545; median 0.291). CONCLUSIONS: Small arteries, arterioles and capillaries are the main affected vessels in SLE. This chronic process stimulates circulation through lower resistance collaterals, decreasing HRI value. The Doppler HRI calculation can be valuable in early diagnosis and monitoring of lower extremity vascular changes in patients suffering from SLE with and without SAPS.

[Intra-arterial thrombolysis for acute angiographically proven occlusion in bifurcation of basilar artery. Case report]. / Dotetnicza tromboliza w ostrej potwierdzonej angiograficznie niedroznosci w rozwidleniu tetnicy podstawnej. Analiza przypadku.

In a 52 year-old male patient with a past history of two strokes, an occlusion of the basilar cerebral artery in the area of bifurcation into the posterior cerebral arteries was angiographically confirmed. Following an intra-arterial application of rt-PA a partial revascularization of the occluded posterior arteries was observed. After an interval of 8 hours rt-PA was administered again, resulting in a complete recanalization of the arteries. The patient's neurological state was stabilized but not improved, despite a systematic anti-thrombotic treatment. His sudden death on the 23rd day of treatment was caused by pulmonary embolism. A postmortem examination indicated a complete patency of the Willis circle. The basilar artery was unchanged, while within the posterior cerebral arteries only a moderate thickening of the intima and a small dissection of the internal elastic membrane were found. There was no evidence of bleeding into the CNS. It was assumed that thrombolysis had resulted in a total revascularization of the occluded region and was uncomplicated. Ischemic changes within the nervous tissue had probably developed before the thrombolytic treatment, and were responsible for the lack of improvement. The patient's death due to pulmonary embolus in spite of the continued anticoagulant treatment, and his history of strokes in the young age, suggested the presence of some coagulation system abnormalities that could not be detected because of the thrombolytic and anticoagulant drugs administration.